Complaint & Appeal AnalystPrimary Location: Richmond, VA
Additional Locations: VA-Richmond Apply
- Research incoming electronic complaints/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 Plan Sponsor claim fiduciary responsibility, assemble data used in making the denial determination, assemble, summarize and send to Plan Sponsor contact.
- 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 of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
- Identify and research all components within member or provider/practitioner complaints/appeals for all products and services.
- Triage incomplete components of complaints/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 technical resource to colleagues on claim research, SPD/COC interpretation, 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.
- Act as single point of contact for the Executive complaints and appeals and Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers, as assigned.
- Experience in reading or researching benefit language in SPDs or COCs.
- 1-2 years experience that includes both HMO and Traditional claim platforms, products, and benefits; patient management; product or contract drafting; 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.
- 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.
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