Aetna Network Relations Specialist in San Diego, California

Req ID: 53097BR

POSITION SUMMARY

The Provider Relations Call Center Representative position maintains and enhances relationships with facilities, physicians and ancillary providers which serve as a contractual network of care for members; foster growth of managed care products.

Fundamental Components:

  • Creates and/or manages cooperative working relationships with providers and through correspondence and telephone contact on topics related to claims, changes to provider data elements, and contract status.

  • Educates providers and Aetna staff, including: assessing needs, designing and developing training and educational materials, training appropriate audiences/customers (e.g., contractual requirements, policies and procedures, etc.), and evaluating training success and modify educational components as needed.

  • Coordinates distribution of educational materials. Plans and coordinates meetings, seminars and conferences. Conducts ongoing analysis and refinement of provider networks to assure appropriate network composition, system maintenance.

  • Implements network development and refinement strategies.

  • Conducts and manages ongoing audits of provider compliance with contractual obligations and plan standards; partners with quality management in identifying and reporting trends.

  • Conducts and manages ongoing audit of provider information.

  • Conducts and manages on-going review of contract installations; partners with quality management in identifying, analyzing and reporting on trends.

  • Provide issue resolution and complex trouble shooting for providers; monitors agreements containing specific time-limited provisions to ensure adherence to expiration dates Works with local contractors and GMs to insure contracts comply with policies and guidelines and if exceptions are necessary, ensures the ability to administer those non-standard contracts.

  • Acts as network expert by developing and participating in presentations to existing customers Analyzes trends and develop reports regarding claims, utilization, and quality management for PCP offices.

  • Identify target offices and consult on utilization patterns and practice management.

BACKGROUND/EXPERIENCE desired:

  • Previous provider relations and claims experience and background desired.

  • Thorough knowledge of managed care business and healthcare environment.

  • Strong organization and communication skills. Proficiency with MS Office Suite.

EDUCATION

  • The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.

ADDITIONAL JOB INFORMATION

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidates'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.

Job Function: Health Care