Appeal and Grievance Coordinator

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

📋 Description

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

• Research incoming electronic cases and direct inappropriate work items accordingly.

• Review plan designs and certificates of coverage to evaluate benefit or administrative denials.

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

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

• Triage incomplete elements to subject matter experts in other departments.

• Coordinate case components and manage final communications for resolution and closure.

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

• Identify trends and emerging issues, report findings, and propose solutions.

⛳️ Requirements

• Must reside in Oklahoma.

• 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 audit experience.

• Familiarity with reading or researching benefit language.

• High school diploma or GED equivalent required.

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

• Capability to make decisions in alignment with 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 detail.

• Understanding of clinical terminology, as well as regulatory and accreditation requirements.

• Excellent verbal and written communication skills.

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

• Some college education preferred.

• Experience in researching and analyzing 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.

• Comprehensive benefits package for eligible full-time colleagues.