Appeals Nurse AnalystPrimary Location: Richmond, VA
Additional Locations: VA-Richmond Apply
Schedule is Monday-Friday standard business hours. One weekend on call rotation.
64383Fundamental Components: Independently researches and translates organizational policy into intelligent and logically written and/or verbal responses to media relations, regulators, government agencies, or cases that come through the executive complaint line, for all products and issues pertaining to members or providers.Manages inventories to ensure state guidelines are met. Responsible for making sure workflows are kept up to date with most current regulations and legislation.Creates and communicates appeal policies, procedures, and outcomes with all levels of the organization.Educates analysts and business units of identified issues and potential risk.Initiates and encourages open and frequent communication between constituents. Dissects policies, trends, and workflows which in turn identify areas in need of improvement throughout various departments.Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases.Independently takes complete ownership of responses as findings may result in mitigating negative publicity or stopping the trigger of an external audit or fine.Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications.Demonstrates strong letter writing skills; drafts individual letters based on current findings, regulations and legislation Background Experience: 3 years of experience in a Complaint and Appeal Analyst role
2 years clinical experience preferred (pharmacy, medical, home health)
3 years of claim research knowledge or claim processing experience; knowledge of tools associated with appeals and claim processing (i.e. CATS, ECHS, ASD, EPDB, SCM, WEB CCI, Plan Sponsor Tool, AST, Claims X-ten, E-policy, IOP)
Experience as an assistant Team Lead, Team Lead or Project Manager preferred
Strong knowledge of the external review process related to DOL and state regulations
Knowledge of ICD-9 and CPT codes preferred
Expert knowledge of the healthcare industry
Bachelor's degree desired or equivalent work experience.
Yellow Belt achievement in Aetna's Process Improvement Program is preferred
LICENSE one of the following is required:
RN Additional Job Information: Independently and accurately able to multi-task projects; ability to be self-sufficient while researching, performing analysis and applying resources necessary to complete a final assessment of the required and appropriate action (verbal and/or written)Negotiation skillsStrong analytical skillsAttention to detailAutonomously makes decisions based upon current policies/guidelinesActs decisively to ensure business continuity and with awareness of all possible implications and impactExpert knowledge of clinical terminology, regulatory and accreditation requirements Required Skills: General Business - Applying Reasoned Judgment, Service - Demonstrating Service Discipline, Service - Working Across Boundaries Desired Skills: Leadership - Driving a Culture of Compliance, Service - Case Administration Functional Skills: Nursing - Clinical claim review and coding Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel Education: Nursing - Registered Nurse Potential Telework Position: No 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.
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