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Credentialing Processor

Primary Location: Plantation, Florida
Additional Locations: FL-Plantation
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Description:
Reviews, analyzes, evaluates, validates provider/producer information against business/credentialing requirements and maintains information in Credentialing Management data bases.

Fundamental Components:
  • Reviews (re)credentialing data for completeness, accuracy and conducts research pertaining to missing data.
  • Performs accurate and timely baseline demographic transaction updates in provider/producer system applications.
  • Analyzes data to identify variances in information furnished by providers/producers against primary verification sources.
  • Utilizes systems to maintain credential files, EPC and CARDS to track queries, documentation of phone calls, correspondence, completed applications, and outcomes.
  • Contacts providers/producers to clarify and resolve data quality issues. Identifies potential risk situations, collects pertinent information and completes investigation.
  • Reports results of credentials findings and document further action needed.Protects the confidentiality and integrity of provider/producer data files.
  • Conducts and manages ongoing review of provider/producer compliance to contract requirements.
  • Researches, investigates, approves and coordinates resolution of business exceptions with internal and external constituents. Identifies and appropriately escalates data transaction and credentialing issues that might potentially have significant adverse impact on service levels.
  • Monitors and reports data elements for quality against standards.
  • Manages incoming requests for provider/producer application and status requests, utilizing systems to determine eligibility for network participation.
  • Performs recredentialing application management process for all outstanding applications at risk of non-compliance. Utilizes data systems to access information to respond to customer service call line questions maintaining service call TAT, ASA and high quality customer satisfaction goals.


Background Experience:
  • College degree or equivalent work experience preferred
  • High School Diploma or G.E.D.


Additional Job Information:
Ability to work reliably, prudently and tactfully with confidential information.Proficient computer skills, including proficiency in Microsoft Word and Excel.Strong verbal and written communication skills.

Required Skills:
General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, General Business - Consulting for Solutions

Desired Skills:
General Business - Maximizing Work Practices, Service - Providing Solutions to Constituent Needs, Service - Working Across Boundaries

Functional Skills:
Network Management - Credentialing, Network Management - Provider relations

Technology Experience:
Aetna Application - QNXT, Database - Intuit QuickBase, Desktop Tool - Microsoft Outlook, Desktop Tool - TE Microsoft Excel

Potential Telework Position:
No

Percent of Travel Required:
N/A

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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