Appeal and Grievance Coordinator

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

📋 Description

• Manage the intake, investigation, and resolution of appeals, complaints, and grievances for all products.

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

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

• Examine claim processing logic, accuracy of claim payments, member eligibility, and billing/payment status.

• Identify and investigate all aspects of member or provider/practitioner cases.

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

• Organize case components, finalize communications, and ensure resolution and closure.

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

• Detect trends and emerging issues, document findings, and propose potential solutions.

⛳️ Requirements

• MUST reside in OK.

• 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.

• Proficient in reading or researching benefit language.

• High School diploma or GED equivalent required.

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

• Ability to make sound decisions based on 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 focus on accuracy and attention to detail.

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

• Outstanding verbal and written communication skills.

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

• Some college education 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, based on eligibility.

• Comprehensive full-time benefits package.