Appeal and Grievance Coordinator

This is a fully remote position, open to applicants in Florida, +4 more states.

📋 Description

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

• Deliver prompt, customer-centric responses to appeals, complaints, and grievances.

• Examine incoming electronic cases and direct inappropriate work items to the correct resources.

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

• Analyze claim-processing logic, member eligibility data, and billing/payment statuses.

• Identify and investigate all aspects of member and provider appeals, complaints, and grievances.

• Direct incomplete components to subject matter experts in various business units.

• Coordinate all elements of cases, including final communications and case closure.

• Act as a technical resource for colleagues on complex issues related to appeals, complaints, and grievances.

• Recognize trends and emerging issues, report findings, and contribute insights for potential solutions.

⛳️ Requirements

• Residency in Kentucky is required.

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

• Proficiency in reading or researching benefit language.

• High school diploma or GED equivalent is essential.

• Capability to thrive in a fast-paced environment with tight deadlines.

• Ability to make informed decisions based on Aetna’s current policies and guidelines.

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

• Strong analytical abilities with a focus on accuracy and attention to detail.

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

• Exceptional verbal and written communication skills.

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

• Some college education is preferred.

• Experience in the research and analysis of claim processing is preferred.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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