Manages the provider configuration team that includes audit, technical and claims analyst staff. Develops processes to collect and maintain accurate and current provider databases relating to provider facilities and provider network. Responsible for development of policies and procedures. Ensures compliance and regulatory requirements are met. Role/responsibilities • Partners with network management/provider relations, health delivery associates and other cross-functional areas to manage highly complex provider configuration and claims issues of a regulatory and/or contractual nature.• Drives change through the business operation to support and changing environment.• Identify, interpret custom or standard contracts (after execution)• Identify, interpret State reimbursement/benefit changes• Provide direction of audits (contract file, provider directory, internal/external audits) and SCR quality review process• Conducts file audits for existing providers• Accountable for team objectives including unit scorecard measures, e.g. Quality and turnaround time of Provider data and configuration transactions.• Recruits, develops, and motivates staff. Initiates and communicates a variety of talent actions including recruitment, talent development, performance management, recognition and pay for performance.• Monitors staff performance, including weekly staff metrics; coaches and mentors staff on performance issues or concerns.• Required to communicate w/internal/external parties by phone/in person; may require travel to offsite locations.• Formulates and implements strategy for the unit to meet objectives and other business initiatives.• Manages and/or participates in selected projects and organizational initiatives.• Cultivates and manages relationships with various external entities, e.g. the state, network providers, vendors, large IPA/PHO's, etc.• Reviews audit results for accuracy and provides guidance to staff on items with critical business implications.• Manages audit process including error correction and rebuttal.• SOX/Internal Claims/ NCQA/ EQRA: Serve on workgroups relative to provider data/loads/claims, etc.• Promotes and educates providers on cultural competency.• Provides support and guidance with comprehension of applicable federal and state regulations, state contracts including NCQA.
Background/Experience Desired • Proven ability to work collaboratively to resolve issues and demonstrates a broad, strategic approach to problem solving.• Demonstrated knowledge of medical cost drivers and managed care industry.• Ability to effect change.• Exercises sound judgment and demonstrates analytical/data-driven decision-making skills.• Able to assess administrative, financial and constituent impact of provider contracts.• Understands provider contracts, contracting options, and operational issues related to provider relations. Education and Certification Requirements Bachelor's degree and 5 or more years of relevant experience preferred.
Please review required qualifications above
Bachelor's degree or equivalent experience
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.
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