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Medicare Appeal Analyst

Primary Location: Cranberry, PA
Additional Locations: PA-Cranberry
Responsible for managing to resolution 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 appeals. Identify trends and emerging issues and report and recommend solutions.

Fundamental Components:
  • Identify correct resource and reroute inappropriate work items that do not meet appeal criteria.
  • Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
  • Responsible for coordination of all components of complaints/appeals including final communication to member/provider for final resolution and closure.
  • Identifies trends and emerging issues and reports on and gives input on potential solutions.
  • Follow up to assure complaint/appeal is handled within established timeframes to meet company and regulatory requirements.

Background Experience:
  • 1-2 years of professional work experience within various backgrounds including but not limited to: Customer Service (Office or Customer Facing), Administrative, Clerical, and Healthcare operations experience.
  • Experience with Microsoft Excel, Word, and Outlook
  • 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:
Finance - Managing Aetnas Risk, General Business - Applying Reasoned Judgment, General Business - Turning Data into Information

Desired Skills:
General Business - Communicating for Impact, General Business - Maximizing Work Practices, Service - Case Administration

Potential Telework Position:

Percent of Travel Required:

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by 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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