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Manager, Provider Network

Primary Location: Linthicum, Maryland
Additional Locations: MD-Linthicum
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Description:
Manages a unit that negotiates, executes, conducts review and analysis, dispute resolution and/or settlement negotiations of contracts with larger and more complex group/system providers in accordance with company standards to maintain and enhance provider networks while meeting and exceeding accessibility, quality and financial goals and cost initiatives. Maintains accountability for specific medical cost initiatives.

Fundamental Components:
Manages a team of professional analysts and negotiators to negotiate complex, competitive contractual relationships with providers according to prescribed guidelines and financial standards in support of national and regional network strategies.
Manages contract performance and supports the development and implementation of standard and/or value-based contract relationships in support of business strategies.
Recruits providers as needed to ensure attainment of network expansion and adequacy targets.
May manage provider contract support functions including the development of boiler plate contracts and state filings; contract support, review & approval, and information analysis to ensure the development of cost-effective provider contracts.
Manages provider compensation/reimbursement and pricing development activities in partnership with business management.
Manages the analysts and contract specialists accountable for cost arrangements within defined groups.
Collaborates cross-functionally to manage provider compensation and pricing development activities, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities.
Partners with business to determine network and contract needs.
Responsible for reporting, understanding and managing medical cost issues and initiating appropriate action in partnership with business.
Serves as SME for less experienced team members and internal partners.
Provides sales and marketing support, community relations and guidance with comprehension of applicable federal and state regulations.
May provide network development, maintenance, and refinement activities and strategies in support of cross-market network management unit.
Assists with the design, development, management, and/or implementation of strategic network configurations and integration activities.
May optimize interaction with assigned providers and internal business partners to manage relationships to ensure provider needs are met.
Ensures resolution of escalated issues related, but not limited to, claims payment, contract interpretation and parameters, or accuracy of provider contract or demographic information.
Initiates legal reviews as needed; ensures all required reviews completed by appropriate functional areas.
Required to communicate with internal/external parties by phone/in person; may require travel to offsite locations.

Background Experience:
5 to 7 years experience in healthcare.
A successful track record of managing and negotiating provider contracts that improve competitive position.
In depth knowledge of various reimbursement structures and payment methodologies.
Solid leadership skills including staff development.
Critical thinking and problem solving skills.
Bachelor's degree or equivalent experience.
Masters degree preferred but not required.

Additional Job Information:
Job description may also be used for other products besides Commercial medical: e.g., dental, worker’s comp, behavioral health, Medicare, Medicaid, etc.; systems and tools mentioned in the description would align and reflect appropriate product, segment.

Required Skills:
Benefits Management - Interacting with Medical Professionals, General Business - Communicating for Impact, General Business - Managing Sales Relationships, Leadership - Collaborating for Results, Leadership - Driving a Culture of Compliance, Leadership - Driving Strategic and Organizational Agility, Leadership - Engaging and Developing People, Sales - Delivering on the Promise, Sales - Negotiating Collaboratively, Service - Handling Service Challenges, Service - Working Across Boundaries

Functional Skills:
Administration / Operation - Management: < 25 employees, Claim - Claim processing - Medical or Hospital- HMO, Claim - Policies & procedures, Clinical / Medical - Network management

Potential Telework Position:
No

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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