Req ID: 29084BR
POSITION SUMMARY
The Complaint Tracking Module (CTM) is used to track, process, and resolve complaints received on behalf of Medicare beneficiaries and providers related to the Medicare Advantage (MA) and Medicare Prescription Drug (Part D) programs. These complaints could be related to both a current or terminated beneficiary. It is our responsibility to investigate, resolve and provide CMS with a timely resolution.
Fundamental Components:
Responsible for the day-to-day management of staff to ensure effective, timely and customer-focused resolution of Medicare member and provider complaints. Oversee complaint investigation process; monitor regulatory compliance and accuracy of outcomes. Research all member and provider issues including Quality of Care, Access to Benefits, Network Issues, Pharmacy, Enrollment/Disenrollment, Billing, Claims, and Marketing Misrepresentation issues. Facilitate communication amongst team members and foster strong collaboration with other business units. Implement new processes that are compliant and in accordance with the Centers of Medicare and Medicaid Services (CMS) regulations as well as Aetna Medicare CTM policies and procedures. Identify complaint trends and issues; provide reports and recommend solutions as appropriate. This includes being accountable for meeting the financial, operational, and quality objectives of the unit. Strong knowledge of CMS systems (i.e., HPMS, MARx) as well Aetna Medicare-related systems (i.e., ASD, GEBAR, MOPS, MedHOK) is a plus.
An Ideal candidate will come from Aetna Medicare Service Operations.
BACKGROUND/EXPERIENCE desired:
Previous Management Experience
Flexibility
Skillful Communicator
Goal Orientated
Problem Solver
Demonstrate Authority
Project management experience.
Experience documenting workflows and reengineering efforts.
EDUCATION
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
FUNCTIONAL EXPERIENCES
Functional - Leadership/Lead a complex or multifunctional organization/1-3 Years
Functional - Products-Medical/All Aetna Medicare Group Plans/1-3 Years
Functional - Management/Management - Medicare/1-3 Years
Functional - Claims/Claim processing - Medical - Medicare/1-3 Years
REQUIRED SKILLS
Benefits Management/Interacting with Medical Professionals/ADVANCED
Leadership/Developing and Executing Strategy/ADVANCED
Service/Handling Service Challenges/ADVANCED
DESIRED SKILLS
Leadership/Collaborating for Results/ADVANCED
Leadership/Creating Accountability/ADVANCED
Leadership/Driving a Culture of Compliance/ADVANCED
ADDITIONAL JOB INFORMATION
Demonstrate an ability to develop, train, evaluate and coach staff to ensure deadlines and quality standards are met.
Act as liaison between staff and other departments to communicate results, ideas, and solutions.
Show an ability to assess individual and team performance on a regular basis and provides timely developmental feedback.
Establish training plans and ensures training needs are met.
An ability to effectively apply and enforce Aetna HR policies and practices, i.e., FML/EML, Attendance, Code of Conduct, Disciplinary Guidelines.
Demonstrate excellent verbal and written communication skills.
A proven ability to prioritize and multi-task in a fast-paced environment.
Establish clear vision aligned with company values; motivates others to balance customer needs and business success.
Perform any other duties and responsibilities as requested.
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.
We conduct pre-employment drug and background testing. Benefit eligibility may vary by position. Clickhereto review the benefits associated with this position.
Job Function: Risk Management