Skip to main content

Manager, Provider Relations (Must reside in Illinois)

Primary Location: Naperville, IL
Additional Locations: IL-Naperville
Manages a team of Provider/ Network Relations supervisors and/or representatives. 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 provider information. Assists in the development of policies and procedures. Manage the development of contracts and agreements with providers and delivery systems in conjunction with network. Engages to ensure compliance and regulatory requirements are met. Develops and implements training programs and educational materials for providers as well as internal staff.

Fundamental Components:
  • Manages a team of supervisors and/or Provider/Network Relations Representatives who maintain the working relationships with existing network and recruit new providers, as well ensure the provider data entered into the provider database is accurate and the provider documentation is complete and accurate.
  • Provides direction to operations teams regarding policy and procedures related to claims/providers.
  • Facilitates Provider Advisory Group meetings and work with management to implement changes; works with Quality Management to develop appropriate provider measures and implement those measures in the provider community. Manages the development and monitoring of provider contracts.
  • Negotiates, reviews, and prepares draft agreements with alternative delivery system facilities, laboratories, and group practices.
  • Coordinates provider status information with member services and other internal departments.
  • Provides service to providers by resolving problems and advising providers of new protocols, policies, and procedures.
  • Develops training materials for staff and provider network; oversees staff responsible for initial and ongoing provider in-services and provider education; develops and implements provider satisfaction surveys.
  • Participates in weekly Grievance and Appeals meetings, tracks and trends provider grievances, monitors staff for timely compliance; complies data and staff metrics in order to complete regulatory deliverables; participates in all internal compliance audits and Regulatory reviews.
  • Researches, reviews, and prepares response for all governmental, regulatory and quality assurance provider complaints; timely and continuous reconciliation of provider records; oversees Provider Access and Availability by reviewing Appointment Availability Audits conducted by staff.
  • Provides support and maintenance assistance for websites, portals, directories, manuals, and dashboards; plans, coordinates, and conducts provider forums and monthly webinars; develops communications including newsletters, notifications and Fax Blasts.
  • Provides assistance and support to other departments, as needed, to obtain crucial or required information from Providers, such as HEDIS, Credentialing, Grievance and Appeals, SIU, etc.
  • Coordinates provider status information with member services and other internal departments.
  • Provide assistance to staff with regard to Finance issues, including but not limited to: checks, refunds, balances, claims settlements.
  • Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including, employment, termination, performance reviews, salary reviews, and disciplinary actions.
  • Monitors staff performance, including weekly staff metrics; coaches and mentors staff on performance issues or concerns.
  • Required to communicate w/internal/external parties by phone/in person; may require travel to offsite locations.

Background Experience:
  • Minimum of 5 to 7 years recent and related experience in Provider Relations.
  • Excellent interpersonal skills and the ability to work with others at all levels.Knowledge of claims, ICD-9, ICD-10 and CPT codes desired.
  • Excellent analytical and problem solving skills.
  • Strong communication, negotiation, and presentation skills.
  • Bachelor’s degree in a closely-related field or an equivalent combination of formal education and recent, related experience.

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.

Clinical Licensure:

Potential Telework Position:

Percent of Travel Required:
25 - 50%

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

Benefit Eligibility:
Benefit eligibility may vary by 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.


Jobs for you

Recently Viewed Jobs

You do not have any recently viewed jobs

Your Saved Jobs

You do not have any saved jobs

Sign up for Job Alerts

Join our Talent Community

At Aetna, a CVS Health Company, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna, a CVS Health Company.

Join Our Talent Community

Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna, a CVS Health Company.