Job Posting for Appeal and Grievance Analyst at new
Job Description **Open to candidates living in the state of Kansas**
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.
Fundamental Components -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. -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 and closure. -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.
Background Experience -Experience in reading or researching benefit language. -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. -Experience in research and analysis of claim processing a plus.
Additional Job Information -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/or provider appeals, complaints and grievance 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.
Education High School diploma, G.E.D. or equivalent experience
Percent of Travel Required 0 - 10%
Business Overview 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.
Salary.com Estimation for Appeal and Grievance Analyst in Overland Park, KS
$34,272 to $46,790
If your compensation planning software is too rigid to deploy winning incentive strategies, it’s time to find an adaptable solution.
Compensation Planning
Enhance your organization's compensation strategy with salary data sets that HR and team managers can use to pay your staff right.
Surveys & Data Sets
Sign up to receive alerts about other jobs with skills like those required for the Appeal and Grievance Analyst.
Click the checkbox next to the jobs that you are interested in.