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TX STAR+PLUS Manager, Grievances and Appeals

Primary Location: Dallas, TX
Additional Locations: TX-Dallas
At Aetna Better Health of Texas, we are committed to helping people on their path to better health. By taking a total and connected approach to health, we guide and support our members so they can get more out of life, every day. We are looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of Texas STAR+PLUS, STAR/CHIP, and STAR Kids members. We value diversity and are dedicated to helping you achieve your career goals.

This position establishes and maintains in collaboration with all segments and business units, consistent policies and procedures defining the administration and resolution of complaints grievances and appeals from Aetna member and providers compliant with legislative, regulatory and accreditation requirements. Maintains this infrastructure to assure ease of use and consistent resolution responses are accessible to all operational resolution teams and business units and subject matter experts.

Fundamental Components:
  • Manages team's productivity and resources, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of customer concerns.
  • Manages a team of clinical and or non-clinical personnel.
  • Serves as a content model expert and mentor to team in regards to Aetna's policies and procedures, regulatory and accreditation requirements.
  • Manages to performance measures and standards for quality service and cost effectiveness and coaches team/individuals to take appropriate action.
  • Select staff using clearly defined requirements in terms of education, experience, technical and performance skills.
  • Build strong functional teams through formal training, diverse assignments, coaching, mentoring and other developmental techniques.
  • Assesses developmental needs and collaborates with others to identify and implement action plans that support the development of high performing teams and individuals.
  • Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn around time for Appeals and Complaints handling.
  • Ensures all Complaints and Appeals units are utilizing the National tracking tool to ensure reporting consistency and trend analysis.
  • Holds individuals/team accountable for results; recognize/reward as appropriate.
  • Lead change efforts while managing transitions within a team.
  • Identifies trends involving non-clinical & clinical issues and reports on and recommends solutions.
  • Additional duties as assigned, (e.g., Supervisors with less than 15 direct reports will also handle resolution work the % of the time they are not managing their staff).
  • Sedentary work involving significant periods of sitting, talking, hearing and keying.
  • Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.
  • Working environment includes typical office conditions.

Working knowledge of Healthcare

1-3 years supervisory experience

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

Background Experience:
  • Bachelor's degree or 5 years equivalent work experience in Healthcare, Project Management, Audit, Systems Design.
  • Experience in research and analysis of claim processing a plus.
  • Experience working with managed and non-managed health care benefits.
  • Strong analytical skills focusing on accuracy and attention to detail.
  • Sound judgement.
  • Product knowledge and experience with Complaints and Appeals and Regulatory Requirements.
  • Knowledge of clinical terminology, regulatory and accreditation requirements.
  • Excellent verbal and written communication skills.

Additional Job Information:

Required Skills:
General Business - Applying Reasoned Judgment, General Business - Demonstrating Business and Industry Acumen, Leadership - Engaging and Developing People

Desired Skills:
Benefits Management - Understanding Clinical Impacts, General Business - Communicating for Impact, General Business - Maximizing Work Practices

Functional Skills:
Administration / Operation - Management: < 25 employees, 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:

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.


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