Consultant

• Intake, investigate, and resolve appeals, complaints, and grievances across products
• Review and resolve clinical documentation, clinical complaints, and appeals
• Review clinical records, interpret data, and apply clinical criteria and policies in line with regulatory and accreditation requirements
• Coordinate clinical resolutions with internal and external clinician support
• Gather data using multiple system applications
• Contact providers, vendors, and internal Aetna departments for additional information
• Apply review requirements to ensure cases are reviewed by practitioners with appropriate clinical expertise
• Process appeals in accordance with regulatory and accreditation standards
• Condense complex information into clear and precise clinical summaries
• Coordinate appeals with members, authorized representatives, providers, regulators, consultants, and other participants
• Report findings to team leaders and supervisors, respond to rebuttal issues, and recommend improvements
• Identify and report trends and emerging issues and provide input on potential solutions

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