Appeal and Grievance Coordinator

This is a fully remote position, open to applicants in Kentucky, +2 more states.

📋 Description

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

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

• Analyze plan design or certification of coverage to assess the accuracy of benefit or administrative denials.

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

• Identify and examine all elements of member or provider appeals, complaints, and grievances.

• Triage incomplete components to relevant subject matter experts.

• Coordinate all elements, including final communication and resolution closure.

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

• Recognize trends and emerging issues, providing potential solutions.

⛳️ Requirements

• Candidates must reside in KY, OK, or OH.

• Experience in interpreting or researching benefit language is essential.

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

• Prior experience in research and analysis of claim processing is advantageous.

• High School diploma or GED equivalent is required.

• Familiarity with member and/or provider appeals, complaints, and grievance policies is necessary.

• Understanding of clinical terminology, regulatory, and accreditation requirements is important.

• Strong analytical skills with a focus on accuracy and attention to detail are required.

• Excellent verbal and written communication skills are a must.

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

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

• Capability to make informed decisions based on Aetna's current policies and guidelines.

• Ability to foster collaborative working relationships.

🏝️ 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, subject to eligibility.