Description: Oversees a department with Provider Relations team to ensure development, education, service, reimbursement and management of existing provider networks, support recruitment, delivery of provider data services including production, quality audit, reporting and process improvement for the business operation. Ensures all contractual metrics specific to provider data management are met and/or exceeded.
Fundamental Components: Oversees teams responsible for the working relationships with the existing and new provider groups within the defined geography; typically consists of network relations consultants, supervisors and managers; may include provider data service and network operations consultants, depending on business configuration.
Ensures the team builds and maintains provider relationships that ensure competitive network coverage, deliver operational efficiencies, ensure compliant administration of contracts, and education that results in overall provider satisfaction.Leads the assessment, development and organizational of the provider network for HMO/PPO/POS and Medicare networks.
Reviews and facilitates contracting of interested providers whose services match a need for Plan access/expansion; with assistance from other internal expertise.
Responsible for provider retention; ensures initial and ongoing provider servicing, as well as provider compliance to policy.
Leads inter-departmental teams as necessary to implement large and/or complex provider contracts and initiatives successfully.
Collaborates with other departments within the organization to ensure key provider reimbursement methodologies and provisions are administratively supported.
Provides sales and marketing support, and community relations with subject matter expertise.
Leads the development and implementation of provider education and communications regarding new protocols and policies and contract compliance requirements; includes provider newsletters, Provider Notifications, Provider forums, webinars, council meetings and Fax Blasts.
Ensures initial provider education and office orientations as well as ongoing visits, are delivered by assigned representatives.
Provides support and maintenance assistance for Provider Website, Provider Portal, Provider Director, and Provider Manual.
Primary provider relations contact for market compliance audits and regulatory reviews.
Gathers information for audits by governmental, regulatory and quality assurance agencies including oversight requirements/surveys required for credentialing and re-credentialing.
Monitors timely compliance with Grievance and Appeals activity; ensures problem resolution and response to all required agencies.
Collaborates with Provider Data Service organization; interacts with the internal departments to resolve provider billing issues.
Responsible for understanding medical cost issues and collaborating to take appropriate action as appropriate
Required to communicate w/internal/external parties by phone/in person; may require travel to offsite locations #LI-HH1
Background Experience: Minimum of 7 - 10 years recent and related experience in Provider Relations.
Recent and related experience in provider contracting and provider office practices.
Very strong communication, negotiation, and presentation skills.
Ability to lead professionals and manage through influence and cooperation.
Excellent interpersonal skills and the ability to work with others at all levels.
Bachelor's degrees in a closely-related field or an equivalent combination of formal education and recent, related experience. 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: Leadership - Anticipating and Innovating, Leadership - Driving Change, Service - Managing Organizational Dynamics Desired Skills: Finance - Profit and Quality Vigilance, General Business - Applying Reasoned Judgment, General Business - Demonstrating Business and Industry Acumen Functional Skills: Administration / Operation - Management: < 25 employees, Claim - Claims Administration - cost management, Communication - Communication Delivery - Public Speaking, General Management - Data analysis & interpretation, Leadership - Lead a business in different geographies or multiple markets, Leadership - Lead a complex or multifunctional organization Potential Telework Position: No 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.