Responsible for the daily operation and direction of the Provider/Network Relations consultants and representatives. Supervises and trains employees who maintain working relationships with the existing provider network and assist in the recruitment of new providers. Ensures the accuracy of current provider databases relating to provider facilities and provider information. Assists with the establishment and interpretation of the department’s policies and procedures.
60612 Fundamental Components: Leads a team of provider/network relations consultants and representatives to ensure the establishment and continuous updating of provider databases and provider documentation; ensures the provider data entered into the database is accurate and that the provider documentation is complete.Oversees the resolution of administrative problems affecting network providers, patients, and Plans within contracted guidelines; resolves problems and advises providers of new protocols, policies, and procedures.Provides oversight of provider claims issues; coordinates and communicates resolution.Negotiates, reviews, and prepares draft agreements with alternative delivery system facilities, laboratories, and group practices.Assesses departmental and provider training needs; develops and implements appropriate training programs.Coordinates provider status information with member services and other internal departments.Performs other related duties as requiredRequired to communicate w/internal/external parties by phone/in person; may require travel to offsite locations Background Experience:
Minimum of 3-5 years recent and related experience in provider network enrollment, contracting, credentialing and provider relations. Supervisory experience required.
Knowledge of ICD-9, ICD-10 and CPT codes desired. Excellent analytical and problem solving skills. Strong communication, negotiation, and presentation skills. Additional Job Information:
Undergraduate degree in a closely-related field or an equivalent combination of formal education and recent, related experience.
Medicaid experience preferred; external travel could be required on an ad hoc basis for provider visits and possible conferences; Required Skills:
Leadership - Collaborating for Results, Leadership - Driving a Culture of Compliance, Service - Improving Constituent-Focused Processes Desired Skills:
General Business - Maximizing Work Practices, Leadership - Collaborating for Results, Leadership - Creating Accountability Functional Skills:
Claim - Claim processing - Medical - Behavioral Health, Claim - Claim processing - Medical or Hospital - ACAS Potential Telework Position:
No Percent of Travel Required:
0 - 10% EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility:
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