Supervisor, Provider Appeals & Grievances - KS MCD

Overland Park, KS
United States

Job Description
Aetna Better Health of Kansas is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you'll join a team dedicated to improving the lives of the most vulnerable in our population. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Kansas, and we will support you all the way.

The Supervisor, Provider Appeals and Grievances is responsible for the day-to-day management of staff to ensure effective resolution of provider/practitioner appeals and grievances. The Supervisor Provider Appeals and Grievances is responsible for organization and development of high performing teams to ensure timely, customer focused response to appeals and grievances. This position facilitates effective interfaces among team members, as well as other business units. The Supervisor, Provider Appeals and Grievances is responsible for day-to-day implementation of Aetna's Provider Appeal and Grievance policies and procedures and identifies trends involving non-clinical (CRT/PRT) or clinical (MRT) issues and reports on and recommends solutions.

Fundamental Components:
- Manages team's productivity and resources, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of customer concerns.
- Serves as a content model expert and mentor to team in regards to Aetna's policies and procedures, regulatory and accreditation requirements.
- Manages to performance measures and standards for quality service and cost effectiveness and coaches team/individuals to take appropriate action.
- Selects staff using clearly defined requirements in terms of education, experience, technical and performance skills.
- Builds strong functional teams through formal training, diverse assignments, coaching, mentoring and other developmental techniques.
- Assesses developmental needs and collaborates with others to identify and implement action plans that support the development of high performing teams and individuals.
- Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turnaround time for Appeals and Grievances handling.
- Identifies trends involving non-clinical & clinical issues and reports on and recommends solutions.
- Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.

Qualification Requirements:
- 1-3 years supervisory experience required.
- Project management experience required.
- Experience documenting workflows and reengineering efforts required.
- Experience working with managed and non-managed health care benefits required.
- Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word required.
- Ability to work across Aetna functions, segments and markets to accomplish business goals.
- Ability to revise priorities as appropriate to respond to change.
- Experience in research and analysis of claim processing required.
- Ability to multi-task to accomplish workload efficiently.
- Excellent verbal and written communication skills.
- Knowledge of clinical terminology, regulatory and accreditation requirements required.
- Knowledge and experience with Appeal and Grievance Regulatory Requirements required.
- Sound judgment required.
- Strong analytical skills focusing on accuracy and attention to detail.
- Prefer active Nursing license (LPN or RN).

The minimum level of education required for candidates in this role is an Associate's degree or equivalent experience.

Active and unrestricted Licensed Practical Nurse (LPN) or Registered Nurse (RN) for the State of KS is preferred.

Functional - Project Management/Project Manager/1-3 Years
Functional - Administration / Operations/Management: < 25 employees/1-3 Years
Functional - Medical Management/Medical Management - Complaints, Grievance & Appeals/4-6 Years

Technical - Desktop Tools/Microsoft Word/4-6 Years/End User
Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/End User
Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
Technical - Desktop Tools/Microsoft SharePoint/4-6 Years/End User

Benefits Management/Interacting with Medical Professionals/ADVANCED
General Business/Communicating for Impact/ADVANCED
General Business/Maximizing Work Practices/ADVANCED

Leadership/Collaborating for Results/ADVANCED
Leadership/Driving a Culture of Compliance/ADVANCED
Service/Creating a Differentiated Service Experience/ADVANCED

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position.

Aetna takes our candidates's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.