Medicaid Appeals & Grievance Associate Manager

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

📋 Description

• Facilitate the effective resolution of appeals, complaints, and grievances from members and/or providers/practitioners.

• Oversee daily staff operations to guarantee efficient and prompt resolutions across all product lines.

• Coordinate input from various business units to address complex issues.

• Execute Aetna's policies and procedures related to appeals, complaints, and grievances.

• Recognize trends and issues; report findings and propose solutions.

• Achieve the financial, operational, and quality goals of the unit.

• Supervise team productivity, resources, workload, and customer satisfaction levels.

• Act as a subject matter expert and mentor on policies, procedures, regulatory, and accreditation standards.

• Manage performance metrics and standards; provide coaching to team members.

• Engage in staff recruitment based on educational background, experience, technical skills, and performance criteria.

• Develop functional teams through training, assignments, coaching, and mentorship.

• Evaluate developmental needs and implement both team and individual development plans.

• Ensure compliance with federal and state regulations and quality standards for letter content and turnaround times.

• Hold teams and individuals accountable for outcomes and recognize or reward performance accordingly.

• Lead change initiatives and manage transitions within the team.

• Investigate and direct incoming electronic appeals, complaints, and grievances.

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

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

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

• Manage a modified caseload and carry out additional assigned responsibilities.

⛳️ Requirements

• Must reside in Louisiana.

• Experience in interpreting or researching benefit language.

• Outstanding verbal and written communication abilities.

• Strong project management capabilities.

• Exceptional customer service skills.

• Experience in documenting workflows and reengineering processes.

• Bachelor's degree or equivalent professional experience.

• Availability to work 40 hours per week.

• Preferred: 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 functions.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Comprehensive benefits package that promotes physical, emotional, and financial well-being.

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.