Job Description:
• Intake, investigate and resolve appeals, complaints and grievances for all products
• Research incoming electronic cases and route inappropriate work items
• Review plan designs and certificates of coverage to assess benefit or administrative denials
• Research claim-processing logic, member eligibility, and billing/payment status
• Identify and research all components of member and provider appeals, complaints, and grievances
• Triage incomplete components to subject matter experts in other business units
• Coordinate case components and final communications for resolution and closure
• Serve as a technical resource to colleagues on appeals, complaints, and grievance issues
• Identify trends and emerging issues, report findings, and recommend solutions
Requirements:
• Must live in Oklahoma
• 1–2 years of experience including claims platforms, products and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service; or audit experience
• Experience reading or researching benefit language
• High school diploma or GED equivalent
• Ability to meet demands of a fast-paced environment with tight turnaround times
• Ability to make decisions based on Aetna's current policies/guidelines
• Thorough knowledge of member and/or provider appeals, complaints and grievance policies
• Strong analytical skills with accuracy and attention to detail
• Knowledge of clinical terminology, regulatory and accreditation requirements
• Excellent verbal and written communication skills
• Computer literacy, including Excel and Microsoft Word
• Some college preferred
• Experience researching and analyzing claim processing preferred
Benefits:
• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being
• Comprehensive benefits package for eligible full-time colleagues