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A new day in healthcare. Together, CVS Health and Aetna help people on their path to better health.

Grievance and Appeal Quality Analyst

Primary Location: New Albany, OH
Additional Locations: OH-New Albany
  • Responsible for consistently auditing complaint and appeal cases, using complaint and appeal approved policies, workflows and manuals, for all resolution teams and products, in a database each month.
  • All errors are applied using documented information.
  • Will also complete coaching when errors/trends are identified.

Fundamental Components:
  • Consistently researches and audits complaints and appeals for all resolution teams each month.
  • Investigate all data used in making audit determinations and can act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures.
  • Expert at researching standard plan design and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial. Can review a clinical determination and understand rationale for decision.
  • Expert at researching various systems to verify accuracy of claim payment, member eligibility data, and billing/payment status.
  • Expert letter writing skills, spelling, grammar, punctuation, inclusion of appropriate letter content, and appropriate state/federal regulatory language when required.
  • Educates team mates as well as other areas on all components within the complaint and appeal area, for all products and services.
  • Fairly evaluates rebuttals at the first level review, using documented workflows/policies.
  • Identifies trends and emerging issues and reports on and gives input on potential solutions.
  • Understands and can audit all resolution teams including, executive complaints and appeals, department of insurance, department of health, or attorney general and state complaints or appeals on behalf of members or providers.
  • Exhibits behaviors outlined in the complaint & appeal quality policies.

Background Experience:
  • Experience in Medicaid and Medicare required
  • 1-3 years experience in a complaint and appeal team preferred
  • Including but not limited claim handling, products, compliance and regulatory analysis
  • Experience in reading and researching benefit language and provider contracts, a plus
  • Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

Additional Job Information:
Ability to adapt to changing priorities. Ability to work independently with limited supervision Demonstrates self-direction and initiative. Ability to adjust to changing priorities and balance the ideal with the practical in achieving results. Ability to work collaboratively within work teams. Clear/concise written and oral communication skills. Ability to work a rotation weekend scheduled, as needed.

Required Skills:
General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, Service - Handling Service Challenges, Service - Improving Constituent-Focused Processes

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. 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.

Click To Review Our Benefits (PDF)


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