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Aetna is now a CVS Health Company

Complaint and Appeal Analyst

Primary Location: Plano, TX
Additional Locations: TX-Dallas, TX-Plano
Responsible for managing to resolution Fast Track Appeal scenarios for Medicare members. Appeals may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to complaints/appeals. Identify trends and emerging issues and report and recommend solutions.

Fundamental Components:
Research incoming electronic appeals to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet complaint/appeal criteria. Research Standard Plan Design or Certification of Coverage pertinent to the member to determine accuracy/appropriateness of benefit/administrative denial. Research claim processing logic to verify accuracy member eligibility data, prior to initiation of appeal process. Identify and research all components within member or provider appeal. Triage incomplete components of appeals to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response. Responsible for coordination of all components of complaints/appeals including final communication to member/provider for final resolution and closure. Serve as a resource to letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise. Identifies trends and emerging issues and reports on and gives input on potential solutions. Follow up to assure complaint/appeal is handled within established timeframe to meet company and regulatory requirements.

Background Experience:
Experience in reading or researching benefit language in SPDs or COCs. 1-2 years experience that includes Medicare products and benefits; patient management; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience. Experience in research and analysis of claim processing a plus. Some college preferred. High School or GED equivalent.

Additional Job Information:
Ability to meet demands of a high paced environment with tight turnaround times. Ability to make appropriate decisions based upon Aetna's current policies/guidelines. Collaborative working relationships. Thorough knowledge of member and provider appeal policies. Strong analytical skills focusing on accuracy and attention to detail. 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.

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. 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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