Manages the activities of the Provider Relations Department.
Overseas the maintenance of working relationships with the existing network, and assists in the recruitment of new providers.
Develops processes to collect and maintain accurate and current provider databases relating to provider facilities and physician information. Assists in the development of policies and procedures.
Develops and implements training programs and educational materials for providers as well as internal staff.
Provides direction to operations regarding policy and procedures related to claims/providers.
Manages a team of Provider Relations Representatives who ensure the provider data entered into the provider database is accurate and the provider documentation is complete and accurate.
Facilitates Provider Advisory Group meetings and works with management to implement suggested changes.
Works with Quality Management to develop appropriate provider measures and implement those measures in the provider community.
Develops provider communications including provider newsletters.
Develops and implements provider satisfaction surveys and uses results to manage relationships and educate staff.
Provides service to providers by resolving problems and advising providers of new protocols, policies, and procedures.
Negotiates, reviews, and prepares draft agreements with alternative delivery system facilities, laboratories, and group practices.
Manages the development and monitoring of provider contracts.
Resolves administrative problems affecting network providers, patients, and Plans within contracted guidelines.
Researches and coordinates the resolution of providers claims and capitation issues.
Coordinates provider status information with member services and other internal departments.
Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including, employment, termination, performance reviews, salary reviews, and disciplinary actions.
Performs other related duties as required.
5+ years recent and related experience in benefits interpretation and provider networking.
5+ years recent and related management/supervisory experience with exempt level staff.
Knowledge of ICD-9 and CPT codes desired.
Excellent analytical and problem solving skills
Strong communication, negotiation, and presentation skills.
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
Management/Management - Multifunctional management :> 25 employees/4-6 Years
General Management/Process & quality improvement/1-3 Years
Claims/Reporting & special services/1-3 Years
Desktop Tools/TE Microsoft Excel/1-3 Years/End User
Desktop Tools/Microsoft Word/1-3 Years/End User
Desktop Tools/Microsoft Outlook/1-3 Years/End User
Desktop Tools/Microsoft PowerPoint/1-3 Years/End User
ADDITIONAL JOB INFORMATION
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 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.