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Medical Encounter/Claim Plan Expert

Primary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix
Involved in initiative planning, ongoing client relationship management and satisfaction for assigned initiatives that impact the delivery of products and services to the internal and external environment (See Family Summary). Collaborates with external vendors, external consultants, consulting team members and/or matrixed staff as required in support of initiatives. Accountable for transferring knowledge, best practices (external and internal), methodology and tools to client organizations. Participates as a team member, may be responsible for concurrent initiatives or act as team lead for less complex projects based on resource requirements. Accountable for the development, implementation and ongoing management of complex system configuration projects which typically impact more than one of the following: process, system, product and/or function and may run a year in duration.

Fundamental Components:
  • Supports holistic solutions and/or key strategic plans.
  • Proactively identifies opportunities for improvement within assigned initiatives Conducts thorough business case and external customer value analysis to determine selection, prioritization positioning and approach for broadest range of potential solutions (e.g., outsourcing, process improvements, technology solutions).
  • Participates in influencing client contracting process, builds optimal client relationship for results and deliverables and manages relationship throughout engagement.
  • Participates and supports metrics integration and execution for optimal results.
  • Shares joint accountability for initiative’s return on investment.
  • Communicates compelling and concise results to empower client groups in decision making process regarding project opportunities.
  • Participates in initiative planning as required.
  • Supports engagement using a disciplined repeatable methodology.
  • Designs, develops interventions and facilitates work sessions.
  • Develops and delivers all required analysis, reporting and presentation materials.
  • Gathers, analyzes and synthesizes business intelligence to drive achievement of strategic business objectives.
  • Builds and utilizes diverse internal and external networks, as appropriate, for data gathering and best practice identification.
  • Leverages internal and external networking to drive optimal initiative results and knowledge/best practice transfer.

Background Experience:
  • 8-10 years experience related to standards & measurements, technology, systems, processes including project consultation.
  • Preferred located in State of Arizona
  • QNXT experience/knowledge required
  • Experience developing and managing multiple budgets for various projects and/or programs.
  • Proven track record meeting project dates and negotiating for resources.
  • Demonstrated negotiation skills.
  • Project management experience.
  • Proven track record in meeting project milestones and negotiating for resources
  • Proven communication skills both written and verbal
  • Past positions required acting a project lead and directing a team
  • Proven ability to affect change/interpersonal skills
  • Solid Project Management and supervisory skills
  • BS/BA or equivalent experience and 5-7 years of management experience related to standards & measurements, technology, systems, processes etc. preferred

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.
  • Highly collaborative process often requires managing relationships across the segments or multiple functional areas.

Required Skills:
General Business - Applying Reasoned Judgment, General Business - Turning Data into Information, Service - Providing Solutions to Constituent Needs

Desired Skills:
Leadership - Collaborating for Results, Leadership - Driving a Culture of Compliance, Technology - Selecting and Applying Technology Solutions

Functional Skills:
Claim - Claim processing - Medical - Behavioral Health, Claim - Claim processing - Medical - Medicare, Claim - Claim processing - Medical or Hospital- HMO, Claim - Policies & procedures, Claim - Quality management, Claim - Reporting & special services, Finance - Financial reporting and analysis, General Management - Data analysis & interpretation, Information Management - Analyzes all types of capitated and fee-for-service provider contracts, performs variance analysis, Information Management - Develops provider compensation and fee schedules, Project Management - Cross-functional project management, Project Management - Evaluating success/lessons learned, Project Management - Issue identification and analysis, Project Management - Project Manager

Technology Experience:
Aetna Application - BMC Remedy 7.5 Suite, Aetna Application - QNXT, Database - Intuit QuickBase, Database - Microsoft SQL Server, Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft PowerPoint, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, 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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