Appeal AnalystPrimary Location: Blue Bell, PA
Additional Locations: PA-Blue Bell Apply
Please bring a copy of your updated Resume
Responsible for managing to resolution complaint/appeal 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 complaints/appeals. Identify trends and emerging issues and report and recommend solutions.
63913Fundamental Components: Research incoming appeals to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeal criteria. Research Standard Plan Design or Certification of Coverage pertinent to the member to determine accuracy/appropriateness of benefit/administrative denial. Research service request to verify accuracy of member eligibility for coverage, prior to initiation of appeal process. Identify and research all components within member or provider/practitioner appeals for all products and services. Triage incomplete components of appeals to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response. Responsible for coordination of all components of appeals including final communication to member/provider for final resolution and timely closure based on regulatory guidelines. Follow up on details of case to assure appeal is handled within established timeframe to meet company and regulatory requirements. Act as point of contact for the Executive complaints and appeals and Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers, as assigned. Ability to collaborate with the clinical team to ensure there is a strong case build prior to case resolution. Background Experience: Experience in reading or researching benefit language in SPDs or COCs.1-2 years experience that includes both HMO and Traditional claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.Experience in research and analysis of claim processing a plus. Some college preferred.High School or GED equivalent. Additional Job Information: Ability to meet demands of a high paced environment with tight turnaround times. Ability to make appropriate decisions based upon Aetna's current policies/guidelines. Collaborative working relationships. Thorough knowledge of member and provider appeal policies. Strong analytical skills focusing on accuracy and attention to detail. Knowledge of clinical terminology, regulatory and accreditation requirements. Excellent verbal and written communication skills. Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word. Required Skills: Benefits Management - Interacting with Medical Professionals, Benefits Management - Promoting Health Information Technology, Benefits Management - Understanding Clinical Impacts, General Business - Communicating for Impact Desired Skills: Service - Handling Service Challenges, Service - Providing Solutions to Constituent Needs, Technology - Justifying the Business Case Functional Skills: Administration / Operation - Data Entry, Claim - Claim processing - Medical - Medicare, Clinical / Medical - Legal & benefit interpretation, Communication - Member communications Technology Experience: Aetna Application - Aetna Administrative System, Aetna Application - Aetna Behavioral Health, Aetna Application - Aetna Document Search, Aetna Application - Aetna Navigator Public Potential Telework Position: Yes 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.
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