Aetna Provider Data Svcs Anly in Arlington, Texas
Req ID: 43870BR
Review new and existing demographic and contract reimbursement arrangements and determine system entry methodology to facilitate accurate and consistent claim adjudication. Provide ongoing business direction relative to provider data structure set-ups in support of claims processing, enrollment/eligibility data, directories, DocFind and physician supplements, Establish, maintain, and align provider demographic and negotiated reimbursement data across Aetna's provider applications - Enterprise Provider Database (EPDB), Mainframe Provider (HMO), and Strategic Contract Manager (SCM) for all products. Assesses all requests for complete and accurate information. Completes contractually sensitive and complex provider data transactions, and directly contacts providers and/or outside vendors to clarify data quality issues. Perform intake triage from various work sources (market, providers, provider call centers, claims, provider solution teams) and respond to network inquiries including: provider requests (e.g. policy & procedures, credentialing status, claims status, provider loads, etc.)
The PDS Analyst has responsibility for maintaining provider demographics in Aetna legacy applications. This includes provider service locations, billing addresses, directory information for both DocFind and hardcopy. Analyst will receive, interpret, and complete requests from various intake sources to keep provider systems as accurate as possible. Analyst is also responsible to ensure proper set up for all providers to their contractual reimbursement for accurate claim adjudication and payment. Position requires strong communication skills, as the position requires frequent interaction with providers, claim contacts, network, and customer service. Establishes, maintains and aligns contracted provider demographic data and negotiated reimbursement arrangements across provider systems () Reviews new and existing contract reimbursement arrangements and determines most appropriate system input methodology that facilitates accurate and consistent claim adjudication () Works collaboratively with internal/external constituents Conducts and manages system audits of PDS systems and user applications Coordinates the receipt of provider data with outside vendors and other entities Partners with outside vendors to review and assess impact of selected contracts to effectively manage potential implications of complex contractual arrangements Completes contractually sensitive and/or complex provider data transactions () Maintains and updates provider demographic and contract information in EPDB, SCM and SCSR () Directly contacts providers and/or outside vendors to clarify data quality issues (*) May provide functional leadership within unit (i.e., team lead or supervise).
Demonstrated PC skills, including Microsoft Office products and Internet navigation skills. Strong Excel skills a plus. Strong Excel skills a plus. Previous industry experience or claims processing preferred. Demonstrated effective communication skills, both verbal and written. Experience with EPDB and Mainframe Provider and other Aetna systems.
The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.
Functional - Claims/Claim processing - Medical or Hospital- HMO/1-3 Years
Functional - Customer Service/Customer Service - Member Services - HMO products/1-3 Years
Functional - Customer Service/Customer Service - Member Services - Traditional products/1-3 Years
Functional - Network Management/Provider data services/
Technical - Aetna Applications/Enterprise Provider Database System/1-3 Years/End User
Technical - Aetna Applications/Strategic Contracts Manager/1-3 Years/End User
Technical - Aetna Applications/Mainframe Provider Database/1-3 Years/End User
Technical - Aetna Applications/DocFind/1-3 Years/End User
General Business/Turning Data into Information/FOUNDATION
Service/Demonstrating Service Discipline/FOUNDATION
Service/Providing Solutions to Constituent Needs/ADVANCED
General Business/Applying Reasoned Judgment/ADVANCED
General Business/Communicating for Impact/ADVANCED
Leadership/Collaborating for Results/FOUNDATION
ADDITIONAL JOB INFORMATION
We are seeking a highly self motivated, results driven experienced professional to join our Provider Data Services team to interpret, establish, and maintain demographic and contractual provider data. Candidate must have excellent organization, communication and analytical skills, and the ability to foster strong, positive working relationships with PDS team members and management, as well as internal and external business partners. Must be a strong team player. Proven ability to effectively prioritize work and meet challenging deadlines. Working knowledge of SCM and other Aetna internal systems. Effective communication skills, both verbal and written. Contract interpretation skills; ability to assess administrative and constituent impact.
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 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.
Job Function: Health Care