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Director, Grievances & Appeals (68293BR)

Primary Location: New Albany, OH
Additional Locations: MI-Detroit, OH-New Albany, TX-Dallas

Directs the grievance and appeals activities for a Health Plan and/or line of business that does business in multiple states. Ensures compliance with all state and federal grievance and appeals laws, the Centers for Medicare and Medicaid Services (CMS) regulations, and applicable accrediting standards (URAC/NCQA). Acts as primary liaison on appeal and grievance activities with all state Departments of Insurance. Develops and implements departmental policies and procedures. Coordinates several markets in which we have dual (Medicare and Medicaid) products.

Fundamental Components:

(*) Responsible for the overall direction and management of all appeals and grievance activities for a Health Plan and/or line of business in compliance with applicable state and federal laws, CMS regulations, accrediting agencies, and company policies and procedures.

(*) Directs production of all appeals reports. Communicates appeals trend results to Health Plan management and the Customer Service Organization (CSO). Provides recommendations to reduce operational appeals issues.

(*) Directs the resolution of all complaints and inquiries for applicable state Departments of Insurance, legislators, and elected officials.

(*) Develops written responses and coordinates hearings for sanctions letters and disciplinary orders to avoid monetary penalties.

(*) Develops and implements departmental policies, procedures, and workflows incorporating new processes into existing systems and workflows while ensuring compliance with federal, state, and accrediting agencies.

(*) Represents the Appeals Department for all audits including pre-exam audit preparation, mock exams, actual audits, preparation of corrective action plans, and follow-up with regulators.

(*) Serves as liaison and key resource to internal departments, legal counsel, corporate government affairs personnel, outside medical review vendors, and external regulatory and accrediting agencies when required.

(*) Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions.

(*) Performs other duties as the need arises.

*Candidates from Ohio, Michigan, and Dallas, Texas are strongly preferred due to the presence of staff at those locations.*

Background Experience:

(*) Previous supervisory and management experience required.

(*) 7-10 years experience directly related to the duties and responsibilities specified or an equivalent combination of education and work experience.

(*) Confirmed written and verbal communication skills.

(*) Able to present information to various audiences.

(*) Validated analytical skills and organization, with superior critical thinking and decision-making skills.

(*) Knowledge of all types of managed care products including HMO, PPO, and Medicare Part D (Medicare desired, not required.)

(*) Previous Appeals Department experience preferred.

(*) Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications.

(*) Master's degree preferred.

(*) Bachelor's degree or equivalent experience.

Required Skills:
Leadership - Developing and Executing Strategy, Leadership - Driving a Culture of Compliance

Desired Skills:
Leadership - Collaborating for Results, Leadership - Creating a World Class Workforce, Leadership - Creating Accountability

Functional Skills:
Risk Management - Management: < 25 employees

Potential Telework Position:

Percent of Travel Required:
10 - 25%

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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