Appeal Examiner - job 2 of 2

Welcome to the team at Aetna! We are currently seeking a highly skilled and experienced Appeal Examiner to join our growing organization. As an Appeal Examiner, you will play a crucial role in ensuring that our members receive the best possible healthcare coverage. We are looking for an individual who is dedicated, detail-oriented, and has a strong understanding of the appeals process in the healthcare industry. If you are passionate about making a positive impact in people’s lives and have the necessary qualifications, we invite you to apply for this exciting opportunity. Join us and be a part of a dynamic team that is committed to providing quality care to our valued members.

Review and evaluate appeal requests from members, providers, and other parties to determine eligibility for coverage and benefits.
Conduct thorough research and investigation into each appeal case, including reviewing medical records and relevant documents.
Ensure that all appeal reviews are completed in a timely and efficient manner, meeting company standards and regulatory requirements.
Communicate appeal decisions to all relevant parties, including members, providers, and internal departments.
Maintain accurate and detailed records of all appeal cases, including documentation of decisions and any necessary follow-up actions.
Collaborate with other departments, such as customer service and claims, to gather necessary information and provide support for appeal cases.
Stay up-to-date on industry regulations and guidelines related to the appeals process and make recommendations for process improvements.
Provide excellent customer service to all parties involved in the appeal process, addressing any concerns or questions in a timely and professional manner.
Participate in training and development opportunities to continuously improve knowledge and skills related to the appeals process.
Adhere to company policies and procedures, as well as regulatory requirements, in all aspects of the job.
Maintain confidentiality of all appeal cases and sensitive information.
Proactively identify and escalate any potential issues or concerns related to appeal cases to the appropriate parties.
Contribute to a positive and collaborative work environment, promoting teamwork and open communication.
Support company goals and initiatives related to providing quality healthcare coverage to members.
Other duties as assigned by management.

Aetna is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate based upon race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.