Job Description
Job Description
Candidate must reside in Allegheny, Fayette, Greene, Washington or Westmoreland county.
Acts as the primary resource for assigned, high profile providers or groups (i.e. local, individual providers, small groups/systems) to establish, oversee, and maintain positive relationships by assisting with or responding to complex issues regarding policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs.
- Optimizes interactions with assigned providers and
internal business partners to establish and maintain
productive, professional relationships
- Monitors service capabilities and collaborates cross-
functionally to ensure that the needs of constituents are
met and that escalated issues related but not limited to,
claims payment, contract interpretation or parameters,
and accuracy of provider contract or demographic
information are resolved
- Supports or assists with operational activities that may
include, but are not limited to, database management,
and contract coordination
- Performs credentialing support activities as needed
- Educates providers as needed to ensure compliance
with contract policies and parameters, plan design,
compensation process, technology, policies, and
procedures
- Meets with key providers periodically to ensure service
levels are meeting expectations
- Manages the development of agenda, validates
materials, and facilitates external provider meetings
- May collaborate cross-functionally on the implementation
of large provider systems, to manage cost drivers and
execute specific cost initiatives to support business
objectives and to identify trends and enlist assistance in
problem resolution
- Conduct standard provider recruitment, contracting, or
re-contracting activities and assist with more complex
contracting and discussions as needed by business
segment
- May provide guidance and training to less experienced
team members
Required Qualifications
- 3+ years' experience in business segment environment
servicing providers with exposure to benefits and/or
contract interpretation
- 3-5 years' experience with business segment specific
policy, benefits, plan design and language
- Strong verbal and written communication, interpersonal,
problem resolution and critical thinking skills
- Working knowledge of business segment specific codes,
products, and terminology
- Bachelors Degree or equivalent combination of
education and experience
Preferred Qualifications
Please review required qualifications above
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.
Candidate must reside in Allegheny, Fayette, Greene, Washington or Westmoreland county.
Acts as the primary resource for assigned, high profile providers or groups (i.e. local, individual providers, small groups/systems) to establish, oversee, and maintain positive relationships by assisting with or responding to complex issues regarding policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs.
- Optimizes interactions with assigned providers and
internal business partners to establish and maintain
productive, professional relationships
- Monitors service capabilities and collaborates cross-
functionally to ensure that the needs of constituents are
met and that escalated issues related but not limited to,
claims payment, contract interpretation or parameters,
and accuracy of provider contract or demographic
information are resolved
- Supports or assists with operational activities that may
include, but are not limited to, database management,
and contract coordination
- Performs credentialing support activities as needed
- Educates providers as needed to ensure compliance
with contract policies and parameters, plan design,
compensation process, technology, policies, and
procedures
- Meets with key providers periodically to ensure service
levels are meeting expectations
- Manages the development of agenda, validates
materials, and facilitates external provider meetings
- May collaborate cross-functionally on the implementation
of large provider systems, to manage cost drivers and
execute specific cost initiatives to support business
objectives and to identify trends and enlist assistance in
problem resolution
- Conduct standard provider recruitment, contracting, or
re-contracting activities and assist with more complex
contracting and discussions as needed by business
segment
- May provide guidance and training to less experienced
team members
Required Qualifications
- 3+ years' experience in business segment environment
servicing providers with exposure to benefits and/or
contract interpretation
- 3-5 years' experience with business segment specific
policy, benefits, plan design and language
- Strong verbal and written communication, interpersonal,
problem resolution and critical thinking skills
- Working knowledge of business segment specific codes,
products, and terminology
- Bachelors Degree or equivalent combination of
education and experience
Preferred Qualifications
Please review required qualifications above
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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