TX STAR+PLUS Complaint & Appeals ConsultantPrimary Location: Dallas, TX
Additional Locations: TX-Dallas, TX-Ennis, TX-Grand Prairie, TX-Greenville, TX-Irving, TX-McKinney, TX-Plano, TX-Terrell Apply
This office based position researches complaints and appeals ensuring compliance with Federal and/or State regulations. Manages control and trend inventory, independently investigates, changes or revises policy to resolve the most escalated cases coming from broad, internal and external constituents for all products and issues. Independently manages 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 a national scope. Must be able to work a weekend rotation.
- Independently researches and translates organizational policy into intelligent and logically written and/or verbal responses to media relations, 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.
- Bachelor's degree desired or equivalent work 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 DOL and state regulations.
- Knowledge of ICD-9 and CPT codes desired.
- Expert knowledge of the healthcare industry.
- Experience as an assistant Team Lead, Team Lead or Project Manager preferred.
- Yellow Belt achievement in Aetna's Process Improvement Program is preferred.
- Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel.
- 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 skills.
- Strong analytical skills.
- Attention to detail.
- Autonomously makes decisions based upon current policies/guidelines.
- Acts decisively to ensure business continuity and with awareness of all possible implications and impact.
- Expert knowledge of clinical terminology, regulatory and accreditation requirements.
Required Skills: General Business - Applying Reasoned Judgment, General Business - Maximizing Work Practices, Service - Improving Constituent-Focused Processes Desired Skills: Benefits Management - Understanding Clinical Impacts, General Business - Communicating for Impact, Leadership - Collaborating for Results Functional Skills: Customer Service - FE Complaints, grievances & appeals Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel 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. 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.
Jobs for you
Recently Viewed Jobs
You do not have any recently viewed jobs
Your Saved Jobs
You do not have any saved jobs
Sign up for Job Alerts
Join our Talent Community
At Aetna, a CVS Health Company, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna, a CVS Health Company.Sign Up
Join Our Talent Community
Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna, a CVS Health Company.