Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Identify trends and emerging issues and report and recommend solutions.
- Research incoming electronic appeals, complaints and
grievance to identify if appropriate for unit based upon
published business responsibilities. Identify correct
resource and reroute inappropriate work items that do
not meet appeals, complaints and grievance criteria.
- Research Standard Plan Design or Certification of
Coverage relevant to the member to determine
accuracy/appropriateness of benefit/administrative
- 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 appeals, complaints and grievance
for all products and services.
- Triage incomplete components of appeals, complaints
and grievance 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
appeals, complaints and grievance including final
communication to member/provider for final resolution
- Serve as a technical resource to colleagues regarding
appeals, complaints and grievance issues, and similar
situations requiring a higher level of expertise.
- Identifies trends and emerging issues and reports on
and gives input on potential solutions.
- 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.
- Experience in reading or researching benefit language.
- 1-2 years experience that includes but is not limited to
claim platforms, products, and benefits; patient
management; product or contract drafting; compliance
and regulatory analysis; special investigations; provider
relations; customer service or audit experience.
- Knowledge of member and/or provider
appeals, complaints and grievance policies.
- Strong analytical skills focusing on accuracy and
attention to detail.
- Excellent verbal and written communication skills.
- Computer literacy in order to navigate through
internal/external computer systems, including Excel and
- Experience in research and analysis of claim processing.
- Knowledge of clinical terminology, regulatory and
-Some college preferred.
-High School or GED equivalent.
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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