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Appeals and Grievance Manager (70955BR)

Primary Location: Overland Park, KS
Additional Locations: KS-Overland Park
Establish and maintain, 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. Maintain 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 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.

(*) Selects staff using clearly defined requirements in terms of education, experience, technical, and performance skills.

(*) Builds 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; recognizes/rewards as appropriate.

(*) Leads change efforts while managing transitions within a team.

(*) Identifies trends involving non-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.)

Background Experience:
(*) Experience in research and analysis of claim processing a plus.

(*) 1-3 years supervisory experience.

(*) Experience working with managed and non-managed health care benefits.

(*) Bachelor's degree or 5 years equivalent work experience in healthcare, project management, audit, and/or systems design.

Additional Job Information:
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.Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.

Clinical Licensure:

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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