Job Description

Position Summary

Responsible for Oversight of that that investigates and resolution of appeals scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals. Identify trends and emerging issues and report and recommend solutions. Independently coaches others on appeals ensuring compliance with Federal and/or State regulations. Manage control and trend inventory, independently investigate, adapts to changes or revise policy to resolve the most escalated cases coming from internal and external constituents for all products. Responsible for serving as the point of contact for the appeal if there is an inquiry from leadership, compliance and State regulators. Understand and adapt to departmental process and policies. Medicare knowledge is a plus. Fast Turn Around of inventory, collaboration with clinical team and management. Attention to detail is needed and must be able to maintain compliance turn-around times, with accurate case resolution or research. Remain a part of the solution by escalating issues that may impact compliance timeliness. Additional duties as assigned which will include a carrying a modified case load including but not limited to:

-Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation requirements.

-Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints and grievances handling.

-Independently researches and translates policy and procedures into intelligent and logically written responses for Executive or Senior leaders on escalated cases.

-Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases.

-Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications.

-Additional duties as assigned which will include a carrying a modified case load including but not limited to:-Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria.

-Research Standard Plan Design or Certification of Coverage (Evidence of Coverage) relevant to the member to determine accuracy/appropriateness of benefit/administrative denial.

-Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.

–Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria.

-Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial.

-Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services.

Required Qualifications

At least 2+ years in one of the following areas: claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience

Preferred Qualifications

Some Medicare and/or Medicaid knowledge

– Experience in reading or researching benefit language

– Ability to work in fast paced, high volume environment

– Excellent verbal and written communication skills

– Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics

– Solution driven and can handle complex issues with accuracy

Education

High School or GED