Complaint and Appeal Consultant

Job Description

Description: Researches complaints and appeals ensuring compliance with Federal and/or State regulations.
Manage control and trend inventory, independently investigate, change or revise policy to resolve the most escalated cases coming from broad, internal and external constituents for all products and issues.
Independently manage all department of insurance and executive complaints.
Responsible for compliance with policies of all applicable Federal and/or State government agencies, including but not limited to Center for Medicaid and Medicare (CMS), Department of Public Welfare, Department of Health, and Department of Insurance.
Responsibilities may have national scope.

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Fundamental Components: Independently researches and translates organizational policy into intelligent and logically written and/or verbal responses to regulators, government agencies, or cases that come through the executive complaint line, for all products and issues pertaining to members or providers.
Manages inventories to ensure state guidelines are met.
Responsible for making sure workflows are kept up to date with most current regulations and legislation.
Creates and communicates appeal policies, procedures, and outcomes with all levels of the organization.
Educates analysts and business units of identified issues and potential risk.Initiates and encourages open and frequent communication between constituents.
Dissects policies, trends, and workflows which in turn identify areas in need of improvement throughout various departments.
Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases.
Independently takes complete ownership of responses as findings may result in mitigating negative publicity or stopping the trigger of an external audit or fine.
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.
Demonstrates strong letter writing skills; drafts individual letters based on current findings, regulations and legislation Background Experience: Minimum of 3-5 years of experience in a Complaint and Appeal Analyst role
At least 5 years of claim research knowledge or claim processing experience; knowledge of tools associated with appeals and claim processing
Strong knowledge of the external review process related to state regulations
Knowledge of ICD-10 and CPT codes desired
Expert knowledge of the healthcare industry
Experience as an assistant Team Lead, Team Lead or Project Manager preferred
Bachelor's degree desired or equivalent work experience.
Yellow Belt achievement in Aetna's Process Improvement Program is preferred Additional Job Information: Independently and accurately able to multi-task projects; ability to be self-sufficient while researching, performing analysis and applying resources necessary to complete a final assessment of the required and appropriate action (verbal and/or written)Negotiation skillsStrong analytical skillsAttention to detailAutonomously makes decisions based upon current policies/guidelinesActs decisively to ensure business continuity and with awareness of all possible implications and impactExpert knowledge of clinical terminology, regulatory and accreditation requirements Potential Telework Position: No Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Candidate Privacy Information: Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.