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• *Position Summary**
Coordinate effective resolution of member and/or provider/practitioner appeals, complaints and grievances.
Responsible for the day-to-day management of staff to ensure effective resolution of member or provider/practitioner appeals, complaints and grievances 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. Responsible for day-to-day implementation of Aetna's appeals, complaints and grievances policies and procedures.
Identifies trends and issues; reports on and recommends solutions. Accountable for meeting the financial, operational, and quality objectives of the unit.
• Manages team's productivity and resources, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of customer concerns.
• Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation requirements.
• Manages to performance measures and standards for quality service and cost effectiveness and coaches the team/individuals to take appropriate action.
• Participation in the staff selection process using clearly defined requirements in terms of education, experience, technical and performance skills.
• Build strong functional teams through formal training, diverse assignments, coaching, mentoring and other developmental techniques.
• Assesses developmental needs and collaborates with others to identify and implement action plans that support the development of high performing teams and individuals.
• Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints and grievances handling.
• Holds individuals/team accountable for results; recognize/reward as appropriate.
• Lead change efforts while managing transitions within a team.
• Identifies trends and emerging issues and reports on and gives input on potential solutions.
• Additional duties as assigned which will include a carrying a modified case load including but not limited to:
• 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 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 appeals, complaints and grievance for all products and services.
• *Required Qualifications
• Experience in reading or researching benefit language.
• Excellent verbal and written communication skills.
• Solid project management skills
• Excellent customer service skills
• Experience documenting workflows and reengineering efforts.
• *Preferred Qualifications
• 1-2 years experience that includes but is not limited too claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.
• *Education**
Bachelor's degree or equivalent experience.
• *Anticipated Weekly Hours**
40
• *Time Type**
Full time
• *Pay Range
• *The Typical Pay Range For This Role Is
$46,988.00 - $102,000.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
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