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Medicare Operations Consultant

Primary Location: Moon township, PA
Additional Locations: PA-Moon township
Serves as subject matter expert for the implementation of all Medicare Part D and Medicare Advantage activities and programs across a market in support of the General Manager. Provides guidance and consultation for new product start-up, program design and regulatory compliance. Provides support for the Medicare Part D and Medicare Advantage operational interface to ensure tactical business goals are achieved across the organization. Supports the CMS bid and application activities.

Fundamental Components:
Serves as subject matter expert for the operational functions of Medicare products within an assigned market. Assists with the execution of all CMS required activities and processes including the accuracy and compliance of the annual bid application, expansion application, member materials, and group setup. Supports internal and external Medicare audit activity including CMS and operation integrity audits. Coordinates file pulls, data requests, universe development, and supporting documentation. Maintains an awareness of trends, developments, and governmental regulations in Medicare and managed health care organizations. Provides consultative support for Medicare product design features, integration schedule, and operational readiness in a new product start-up environment. May participate on various committees to represent the Medicare Department including NCQA, Internal Research, UM/QI, Trend/MER, Risk Mitigation, Complaint and Appeals, bid, implementation, and migration. Supports member retention activities, including development of outreach materials, design/implementation of outreach programs both directly and in coordination with corporate member retention team, development of talking points/educational pieces about market specific issues. Monitors sales and marketing activities to assure adherence to Federal and State regulations. Performs other related duties as assigned.

Background Experience:
Able to effectively coordinate multiple projects and programs in a matrix environment and work independently.Excellent consulting and leadership skills.Familiarity with regulations and statutes impacting the managed care environment.Ability to perform analysis and legal research to identify and clarify issues.Previous experience (5-7 years) in Medicare Operations and/or Medicare compliance functions.Excellent communication, interpersonal and presentation skills.Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications. Bachelor's degree desired or equivalent work experience.

Required Skills:
General Business - Applying Reasoned Judgment, Leadership - Developing and Executing Strategy, Service - Improving Constituent-Focused Processes

Functional Skills:
Customer Service - Call center monitoring & analysis - Inbound calls - call center location, Management - Management - Operations, Project Management - Issue identification and analysis

Technology Experience:
Aetna Application - Avaya Interaction Center, Database - Intuit QuickBase, Desktop Tool - TE Microsoft Excel

Potential Telework Position:

Percent of Travel Required:
0 - 10%

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.


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