Job Description
Job Description
Provides leadership and maintains oversight of functions within Networks Operations for the following teams: Implementations, Business Analysts, Agile Product Owner, Network Administrators, and Network Repricing File & Vendor Management. Executes local strategic and operational plan in support of business segment customer service objectives and initiatives. Plans, directs and implements procedures that will assure a high level of customer access and satisfaction. Responsible for the quality and effectiveness of own team and related teams, identifying and resolving technical, operational and team issues. Manages a team of professional employees. Oversees Network Operations that consists of three units that perform the following functions:1) Network Implementations / Business Analysts
* Subject matter expert for network files and PPO codes
* Agile Team product owner for Claims Routing Operations
* Submits IT tickets and performs UAT for new implementations and issue resolution
* Performs research for network issues and partners with EDI IT and Wholesale Operations on resolution
* Coordinates provider directory implementations and research/resolves technical issues
2) Network Administrators
* Acts as the PPO network vendor liaison
* Provides network operational support
* Maintains provider demographics
* Uploads Fee Schedules
3) Network File Management
* Maintains relationship with PPO network router vendor
* Monitors claims daily inventory report and triages potential file issues
* Supports and acts as repricing subject matter experts for PPO and OON networks
Effectively applies and enforces Aetna HR policies and practices, i.e. FML/EML, Attendance, Code of Conduct, and Disciplinary Guidelines. Effectively manages cross-functional projects that support the business strategy.
Required Qualifications
- Demonstrated issue resolution
- 3+ years proven leadership experience setting strategic direction and influencing change that resulted in quantifiable positive outcomes
- Proven strong leadership skills managing large high performance teams
Preferred Qualifications
- 5+ years experience in managing business analysts, project delivery, production, implementation, audits, UAT, and vendor relationships.
- Healthcare experience preferred
- Experienced working with vendors
- Network Operations experience
Education
Bachelor's degree or equivalent experience.
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
Provides leadership and maintains oversight of functions within Networks Operations for the following teams: Implementations, Business Analysts, Agile Product Owner, Network Administrators, and Network Repricing File & Vendor Management. Executes local strategic and operational plan in support of business segment customer service objectives and initiatives. Plans, directs and implements procedures that will assure a high level of customer access and satisfaction. Responsible for the quality and effectiveness of own team and related teams, identifying and resolving technical, operational and team issues. Manages a team of professional employees. Oversees Network Operations that consists of three units that perform the following functions:1) Network Implementations / Business Analysts
* Subject matter expert for network files and PPO codes
* Agile Team product owner for Claims Routing Operations
* Submits IT tickets and performs UAT for new implementations and issue resolution
* Performs research for network issues and partners with EDI IT and Wholesale Operations on resolution
* Coordinates provider directory implementations and research/resolves technical issues
2) Network Administrators
* Acts as the PPO network vendor liaison
* Provides network operational support
* Maintains provider demographics
* Uploads Fee Schedules
3) Network File Management
* Maintains relationship with PPO network router vendor
* Monitors claims daily inventory report and triages potential file issues
* Supports and acts as repricing subject matter experts for PPO and OON networks
Effectively applies and enforces Aetna HR policies and practices, i.e. FML/EML, Attendance, Code of Conduct, and Disciplinary Guidelines. Effectively manages cross-functional projects that support the business strategy.
Required Qualifications
- Demonstrated issue resolution
- 3+ years proven leadership experience setting strategic direction and influencing change that resulted in quantifiable positive outcomes
- Proven strong leadership skills managing large high performance teams
Preferred Qualifications
- 5+ years experience in managing business analysts, project delivery, production, implementation, audits, UAT, and vendor relationships.
- Healthcare experience preferred
- Experienced working with vendors
- Network Operations experience
Education
Bachelor's degree or equivalent experience.
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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