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Medicare STARS/RAF Lead

Primary Location: Falls Church, Virginia
Additional Locations: VA-Falls Church, VA-Richmond
Local quarterback with dual responsibilities in maintaining/improving market Stars ratings and risk adjustment; executes on STARS strategy as (local) extension to Segment best practices / resources

Fundamental Components:
Works across local market leadership to establish and champion for a local market culture committed to STARS and RAR excellence
Focused on quality, executing on national initiatives at local level
Identify and develop local market STARS and quality strategies; manage local quality programs (e.g., PEP)
Monitor and trend member complaints, grievances and appeals in the local market and support local activities to mitigate issues
Manage and direct local vendors
Ensure compliance across various elements to minimize risk
Conduct data analysis, in conjunction with national tools, to identify opportunity areas and paths on track; assure member metrics being met
Identify which VBCs/non-VBCs to prioritize with HEDIS and RA initiatives
Produce content for training tools for agents developed around market needs (CTM drivers, RAF trends)
Engage with clinical team and specific clinics, medical groups, hospitals; attends JOM meetings; Supports engagement managers and RN program managers
Support local market colleagues in ensuring strategic and optimal bids; attends/hosts trainings
Additional dock-in points needed to manage include MSO, product, sales, network, performance, MEU

Background Experience:
Health insurance / managed care
Quality standards principles, including Stars, HEDIIS, MRA
Ability to foster trust/relationships with key provider groups
Strong data and financial analysis acumen
Supervisory experience
Ability to execute strategy and devise plans

Additional Job Information:
Team leadership and team building skills.
Analytical and planning skills.
Negotiation/influencing skills.
Relationship and change management skills.
Organizational skills.
Time management skills.
Critical thinking skills.
Oral and written communication skills.

Required Skills:
Benefits Management - Maximizing Healthcare Quality, Benefits Management - Understanding Clinical Impacts, Finance - Managing Aetnas Risk

Desired Skills:
Benefits Management - Understanding Clinical Impacts, Finance - Creating Profitable Partnerships, General Business - Consulting for Solutions

Functional Skills:
Claim - Claim processing - Medical - Medicare, Claim - Claim processing - Medical or Hospital- HMO, Claim - Quality management, Clinical / Medical - Clinical claim review & coding

Technology Experience:
Aetna Application - Aetna Encounter Processing System, Aetna Application - Aetna Pharmacy Management Claim Adjudication Sys

Potential Telework Position:

Percent of Travel Required:
10 - 25%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
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.

Click To Review Our Benefits (PDF)


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