Skip to main content

Aetna is now a CVS Health Company

Appeals Nurse Analyst

Primary Location: Richmond, VA
Additional Locations: VA-Richmond
Independently coaches others on complaints and appeals ensuring compliance with Federal and/or State regulations. Manage control and trend inventory, independently investigate, change or revise policy to resolve the most escalated cases coming from broad, internal and external constituents for all products and issues. Independently manage all department of insurance and executive complaints, and solely responsible for handling and responding to all media relations. Responsible for compliance with policies of all applicable Federal and/or State government agencies, including but not limited to Center for Medicaid and Medicare (CMS), Department of Public Welfare, Department of Health, and Department of Insurance. Responsibilities may have national scope.

Schedule is Monday-Friday standard business hours. One weekend on call rotation.

Fundamental 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:

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

Nursing - Registered Nurse

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)


Jobs for you

Recently Viewed Jobs

You do not have any recently viewed jobs

Your Saved Jobs

You do not have any saved jobs

Sign up for Job Alerts

Join our Talent Community

At Aetna, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna.

Join Our Talent Community

Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna.