Description: Reviews, analyzes, evaluates, validates provider/producer information against business/credentialing requirements and maintains information in Credentialing data bases. Supports extensive research and analysis of sensitive provider/producer issues; addresses data integrity issues.
Maintains high production and quality factors.
Participates in development of credentialing processes and workflows.
Identifies improvement opportunities and recommends enhancements and workable solutions.
Provides telephonic education to providers/producers on credentialing policies and procedures.
Identifies and communicates trends (quality of results, efficiencies of processes).
Researches and prepares risk sensitive or complex business review/credentialing verification items for CPC.
Reviews completed investigative files of co-workers for completion and accuracy.
Manages vendor on-line access of primary verification sources.
Provides ongoing support to department members in completing research and analysis to resolve complex issues raised by providers/producers and other internal/external customers.
Directly contacts providers/producers and/or outside entities to clarify data quality issues.
Provides issue resolution for providers/producers, during the credentialing or data management processes.
Responds to network or provider/producer inquiries, including contracting and credentialing policy, procedures, credentialing status.
Perform data entry and systems maintenance as needed; align data across systems.
Ongoing License Sanction monitoring and reporting to minimize corporate risk.
Track record of prioritizing work, multi-tasking, and managing workload efficiently.
College degree or equivalent work experience preferred.
High School Diploma or G.E.D.
Additional Job Information:
Possesses a working knowledge of Business Review/Credentialing processes, EPDB, EPC and CARDS.
Ability to consistently meet and/or exceed performance/production goals.
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.