Skip to main content

Claims Resolution

Primary Location: Richmond, VA
Additional Locations: VA-Richmond
Serves as the subject matter expert in support of contracting initiatives and data audits to enhance provider networks while meeting and exceeding accessibility, compliance, quality, and financial goals. Responsible for reviewing, building and auditing complex contract and network data, support recruitment efforts, and collaborate on negotiations as needed.

Fundamental Components:
  • Responsible for reviewing, building, loading, and auditing complex contracts, agreements, amendments and/or fee schedules in contract management systems.
  • Conducts research, analysis and/or audits to identify issues and propose solutions to protect data, contract integrity and performance.
  • Provides technical expertise for questions related to contracting and related systems and information contained.
  • Partner across the organization to support network development, maintenance, refinement activities, regulatory filings, migration and rate activities.
  • May coordinate complex contracting activities, implementation, coordinate receipt and processing of contracts and documentation and pre-and post-signature review of contracts and language modification.
  • Collaborates on negotiations or may handle contracting and re-contracting discussions with solo providers or small groups.
  • May conduct or assist with service activities such as provider education, technology usage, or process updates.
  • May recruit providers in support of network management and expansion initiative or analyze market data for outreach mailings to desired expansion targets

Background Experience:
  • 5 years related experience.Knowledge of basic negotiating skills desired.Proven working knowledge of standard provider contracts, terms and language desired.
  • Strong communication, critical thinking, problem resolution and interpersonal skills.
  • Bachelor’s Degree or equivalent combination of education and experience.

Additional Job Information:
  • Serve as main point of contact for large health systems in Virginia, to assist in claims research and resolution.

Required Skills:
General Business - Demonstrating Business and Industry Acumen, General Business - Ensuring Project Discipline, General Business - Turning Data into Information

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

Functional Skills:
Claim - Claim processing - Medical - Behavioral Health, Claim - Policies & procedures

Technology Experience:
Aetna Application - QNXT, Desktop Tool - Microsoft Outlook, 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.

Click To Review Our Benefits (PDF)


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, 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.

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.