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Aetna is now a CVS Health Company

Network Operations Lead

Primary Location: St Louis, MO
Additional Locations: CO-Denver, IA-Urbandale, IL-Champaign, KS-Overland Park, KS-Wichita, MO-St Louis, NE-Omaha

Manages all aspects of networkoperations in support of Network/Cost Leader and Market Presidents and acts ascoordination point across all business partners; key internal role responsiblefor maintaining network operations, supporting various activities associateswith network filings, network compliance and dispute re solution/litigation

Fundamental Components:

Partner across the organizationto support network development, maintenance, refinement activities, regulatoryfilings, migration and rate activities to ensure consistent and efficientoperations across market

Specific focus and priorities of role will be at thediscretion of the Market President and Network/Cost Leader as needed across themultiple Heartland markets

Manages and maintains accuracy of provider data incollaboration with Provider Data Operations organization

Compiles/prepares case files (e.g., analytics,paperwork, etc.) and manages independent provider dispute resolution process(e.g., “surprise bill”); supports Network/Cost Leader and Market President, inpartnership with Legal, in managing litigation (e.g., panels, hearings,depositions, arbitration, court appearances)

Responsible for understanding policy changes andassessing how changes impact network strategy, as well as state and Medicareregulatory compliance; prepares and submits required state and CMS filings

Partners closely with National Network functionsincluding Provider Operations and Data Services

ABX initiatives/tools forprocess improvement and end to end focus

Background Experience:
8 – 10 years related experience in health operations, network relations and development, command of financials and pricing strategies, and sales interface. Experience building and maintaining relationships with provider systems. A successful track record managing and negotiating major provider contracts. In depth knowledge of various reimbursement structures and payment methodologies for both hospitals and providers/providers. Knowledge and experience with value based contracting and accountable care models In-depth knowledge of managed care business, regulatory /legal requirements. Solid leadership skills, including staff development and talent management Bachelors degree or equivalent work experience. MBA/Masters degree preferred

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.

Required Skills:
General Business - Demonstrating Business and Industry Acumen, Leadership - Creating a World Class Workforce

Desired Skills:
Leadership - Driving Strategic and Organizational Agility

Functional Skills:
Network Management - Contract negotiation, Network Management - Provider data services

Technology Experience:
Desktop Tool - Microsoft Outlook

Potential Telework Position:

Percent of Travel Required:
10 - 25%

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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