Mar 26, 2020

Manager -- Provider Relations

  • Professional Diversity Network
  • New York, NY, USA
Full-Time Other

Job Description


Description: Manages a team of Provider/Network Relations supervisors and/or representatives. Oversees the maintenance of working relationships with the existing network and assists in the recruitment of new providers. Develops processes to collect and maintain accurate and current provider databases relating to provider facilities and provider information. Assists in the development of policies and procedures. Manages the development of contracts and agreements with providers and delivery systems in conjunction with network. Engages to ensure compliance and regulatory requirements are met. Develops and implements training programs and educational materials for providers as well as internal staff.


Fundamental Components: (*) Manages a team of supervisors and/or provider/network relations representatives who maintain the working relationships with the existing network and recruits new providers, as well as ensures the provider data and documentation entered into the provider database is complete and accurate.

(*) Provides direction to operations teams regarding policies and procedures related to claims/providers.

(*) Facilitates Provider Advisory Group meetings and works with management to implement changes; works with Quality Management to develop appropriate provider measures and implements those measures in the provider community.

(*) Manages the development and monitoring of provider contracts.

(*) Negotiates, reviews, and prepares draft agreements with alternative delivery system facilities, laboratories, and group practices.

(*) Coordinates provider status information with member services and other internal departments.

(*) Provides service to providers by resolving problems and advising providers of new protocols, policies, and procedures.

(*) Develops training materials for staff and provider network; oversees staff responsible for initial and ongoing provider in-services and provider education; develops and implements provider satisfaction surveys.

(*) Participates in weekly Grievance and Appeals meetings, tracks and trends provider grievances, monitors staff for timely compliance; compiles data and staff metrics in order to complete regulatory deliverables; participates in all internal compliance audits and regulatory reviews.

(*) Researches, reviews, and prepares responses for all governmental, regulatory and quality assurance provider complaints; timely and continuous reconciliation of provider records; oversees Provider Access and Availability by reviewing Appointment Availability Audits conducted by staff.

(*) Provides support and maintenance assistance for websites, portals, directories, manuals, and dashboards; plans, coordinates, and conducts provider forums and monthly webinars; develops communications including newsletters, notifications and Fax Blasts.

(*) Provides assistance and support to other departments as needed, to obtain crucial or required information from providers, such as HEDIS, Credentialing, Grievance and Appeals, SIU, etc.

(*) Coordinates provider status information with member services and other internal departments.

(*) Provides assistance to staff with regard to finance issues, including, but not limited to: checks, refunds, balances, claims settlements.

(*) Recruits, develops, and motivates staff.

(*) Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions.

(*) Monitors staff performance, including weekly staff metrics; coaches and mentors staff on performance issues or concerns.

(*) Required to communicate with internal and external parties by phone and/or in person; may require travel to offsite locations. Background Experience: (*) Minimum of 5 to 7 years recent and related experience in Provider Relations.

(*) Excellent interpersonal skills and the ability to work with others at all levels.

(*) Knowledge of claims, ICD-9, ICD-10 and CPT codes desired.

(*) Excellent analytical and problem solving skills.

(*) Strong communication, negotiation, and presentation skills.

(*) Bachelor's degree 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. Potential Telework Position: Yes Percent of Travel Required: 10 - 25% 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.





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