Req ID : 51350BR
Requirements : · Responsible for investigating and resolving complaint and appeal scenarios for the Actisure and Open Health business platform, which may contain multiple issues, and the co-
ordination of a response that incorporates input from multiple business units, including external vendors.· Timely, customer-
focused response to complaints and appeals. · Review and analysis of plan documents, company policies, internal processes and regulatory requirements in order to make decisions and recommendations as to how to resolve issues.
Develop and maintain strong collaborative relationships with many operational areas, including but not limited to Member Services, Claims, Plan Sponsor Services, Compliance, Legal, Complaints Grievance & Appeals and external vendors.
Trend analysis on issues and recommended training and business solutions are expected.· Work closely with the Aetna International Compliance Team to identify and analyze route causes of complaints and appeals.
Responsible for producing management information for regulatory reports.· Working closely with the Compliance Team to produce timely reports and analysis statistics.
Managing multiple assignments, accurately and efficiently. · Build relationships while coordinating with multiple business units.
Identify complaint trends and issues and recommend business solutions. Required Competencies : · Excellent written and verbal communication skills· Strong organization, co-
ordination and prioritization skills· Good knowledge of health care processes · Ability to research claim processing logic to verify accuracy of claim payment, member eligibility data, billing-
payment status, prior to initiation of complaint / appeal process · Ability to research standard plan design or certification of coverage pertinent to the member to determine accuracy, appropriateness of benefits and liability denial · Knowledge of legislation and regulations for the markets we operate in· Ability to influence a variety of business areas to resolve complaints and appeals within the local regulators required timeframes · Good utilization of Microsoft Office Software Skills and experience requirements : · Extensive knowledge of health claims processing.
excellent service by meeting quality and turnaround key performance metrics and meeting productivity expectations. · Excellent letter writing skills to convey a positive, professional image with our internal and external customers is essential.
Proven ability to produce and analyze complaint / appeal statistics and written reports relating to complaint handling, resolution and tracking.
Excellent quality results, analytical and communication skills. · Demonstrate the ability to build a strong internal network and effective influencing skills in order to recommend resolutions within regulatory timeframes.
Effective analysis skills to identify the complaint / service issue and recommend an appropriate resolution.· Knowledge of the legal and regulatory environment surrounding complaints and appeals.
Education : The highest level of education desired for candidates in this position is a bachelor s degree or equivalent experience. #LI-BR1
Job Function : Risk Management