Senior Manager - Complaint & Appeals
Core
Coordinate resolution of member and provider appeals, complaints, and grievances while establishing consistent policies and procedures compliant with legislative and regulatory requirements.
Role type
Senior Manager, Appeals & Grievances
Builds
Operational resolution infrastructure and high-performing teams for Aetna plans
Domain
Healthcare insurance / Regulatory compliance
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
Team management, regulatory compliance, performance coaching, trend analysis, staff selection, change management, quality assurance, resource balancing, policy development, federal/state requirements knowledge
Preferred skills
Analytical skills, clinical terminology knowledge, product knowledge in A&G, sound judgement, computer literacy
Technologies
Excel, Microsoft Word, National tracking tool
Responsibilities
Manage team productivity and resources to achieve customer satisfaction; Serve as content model expert and mentor for plan policies; Coach individuals and teams on performance measures and quality standards; Ensure work meets federal and state requirements for appeals and grievances; Identify trends in non-clinical and clinical issues and recommend solutions; Lead change efforts and manage team transitions.
Seniority
Senior, hands-on IC with supervisory responsibilities