Appeal and Grievance Coordinator

This is a fully remote position, open to applicants in Oklahoma.

📋 Description

• Intake, investigate, and resolve appeals, complaints, and grievances across all product lines.

• Examine incoming electronic appeals, complaints, and grievances, directing inappropriate work items accordingly.

• Analyze plan design and certification of coverage to evaluate benefit or administrative denials.

• Investigate claim processing logic, claim payment accuracy, member eligibility, and billing/payment status.

• Identify and assess all elements of member or provider/practitioner appeals, complaints, and grievances.

• Channel incomplete components to subject matter experts in different business units.

• Oversee all components leading to final communication and resolution closure.

• Act as a technical resource for colleagues concerning appeals, complaints, and grievance matters.

• Recognize trends and emerging issues, reporting potential solutions.

⛳️ Requirements

• Must reside in Oklahoma.

• High School diploma or GED equivalent required.

• Experience in interpreting or researching benefit language.

• 1-2 years of experience with claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or auditing.

• Capability to thrive in a fast-paced environment with strict turnaround timelines.

• Ability to make sound decisions in alignment with Aetna's current policies and guidelines.

• Strong collaborative working relationships.

• Comprehensive knowledge of member and/or provider appeals, complaints, and grievance policies.

• Excellent analytical skills with a keen focus on accuracy and detail.

• Familiarity with clinical terminology, regulatory standards, and accreditation requirements.

• Outstanding verbal and written communication abilities.

• Proficiency in computer applications, including Excel and Microsoft Word.

• Some college education is preferred.

• Experience in research and analysis of claim processing is a plus.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being, based on eligibility.