Appeal and Grievance Coordinator

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

📋 Description

• Handle the intake, investigation, and resolution of appeals, complaints, and grievances across all product lines.

• Facilitate responses from various business units for cases that involve multiple issues.

• Investigate incoming electronic work items and redirect those that do not fulfill the relevant criteria.

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

• Examine claim processing logic, member eligibility information, and billing/payment status prior to commencing appeals.

• Identify and investigate all elements related to member or provider/practitioner cases.

• Direct incomplete case components to subject matter experts in other departments.

• Oversee final resolution communications to members or providers and ensure case closure.

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

• Recognize trends and emerging issues, report findings, and propose potential solutions.

⛳️ Requirements

• High School diploma or GED equivalent.

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

• Familiarity with reading or researching benefit language.

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

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

• Ability to build collaborative working relationships.

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

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

• Knowledge of clinical terminology and regulatory/accreditation requirements.

• Exceptional verbal and written communication skills.

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

• Some college education is preferred.

• Experience in researching and analyzing claim processing is an advantage.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial well-being.