Aetna Supervisor, Complaint & Appeal in Pittsburgh, Pennsylvania

Req ID: 45548BR


Responsible for the day-to-day management of staff to ensure effective resolution of member or provider/practitioner complaints/appeals. Responsible for organization and development of high performing teams to ensure timely, customer focused response to appeals. Facilitates effective interfaces among team members, as well as, other business units. Responsible for day-to-day implementation of Aetna's complaints and appeals policies and procedures. Identifies trends involving non-clinical (CRT/PRT) or clinical (MRT) issues and reports on and recommends solutions. Accountable for meeting the financial, operational, and quality objectives of the unit.

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. (*)

Manages a team of clinical and or non-clinical personnel (clinical mgmt for clinical staff/MRT. (*)

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. (*)

Select staff using clearly defined requirements in terms of education, experience, technical and performance skills. (*)

Build 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 turn around time for Appeals and Complaints handling. (*)

Ensures all Complaints and Appeals units are utilizing the National tracking tool to ensure reporting consistency and trend analysis. (*)

Holds individuals/team accountable for results; recognize/reward as appropriate. (*)

Lead change efforts while managing transitions within a team. (*)

Identifies trends involving non-clinical & clinical issues and reports on and recommends solutions. (*)

Additional duties as assigned, (e.g., Supervisors with less than 15 direct reports will also handle resolution work the % of the time they are not managing their staff).

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.

Exhibits the following Cmplaint & Appeal Supervisor Behaviors


1-3 years Part D Appeals Experience; Required

Project management experience.

Experience documenting workflows and reengineering efforts.

Ability to identify options that add value to constituents.

Ability to work across Aetna functions, segments and markets to accomplish business goals.

Ability to revise priorities as appropriate to respond to change

Ability to multi-task to accomplish workload efficiently


The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.


Pharmacy/Pharmacy Technician is desired


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. Click here to review the benefits associated with this position.

Aetna takes our candidate'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.

Job Function: Risk Management