Aetna Credentialing Processor in Sugar Land, Texas

Req ID: 42671BR


Reviews, analyzes, validates provider/producer information against business/credentialing/regulatory requirements and maintains information in credentialing data bases. Supports extensive research and analysis of sensitive provider/producer issues; addresses data integrity issues.

Fundamental Components:

Reviews (re)credentialing data for completeness, accuracy and conducts research pertaining to missing data Performs accurate and timely baseline demographic transaction updates in provider/producer system applications. Analyzes data to identify variances in information furnished by providers/producers against primary verification sources. Utilizes systems to maintain credential files, to track queries, documentation of phone calls, correspondence, completed applications, and outcomes. Contacts providers/producers to clarify and resolve data quality issues. Identifies potential risk situations, collects pertinent information and completes investigation. Reports results of credentials findings and document further action needed. Protects the confidentiality and integrity of provider/producer data files. Conducts and manages ongoing review of provider/producer compliance to contract requirements. Researches, investigates, approves and coordinates resolution of business exceptions with internal and external constituents. Identifies and appropriately escalates data transaction and credentialing issues that might potentially have significant adverse impact on service levels. Monitors and reports data elements for quality against standards. Manages incoming requests for provider/producer application and status requests, utilizing systems to determine eligibility for network participation. Performs re-credentialing application management process for all outstanding applications at risk of non-compliance. Utilizes data systems to access information to respond to customer service call line questions maintaining service call TAT and high quality customer satisfaction goals


1-3 years Customer service experience is REQUIRED.

Prior experience in credentialing a plus, ability to multi - task is important, knowledge of Microsoft office is essential, great attention to detail and ability to work independently


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


General Business/Demonstrating Business and Industry Acumen/FOUNDATION

General Business/Turning Data into Information/FOUNDATION

Service/Demonstrating Service Discipline/FOUNDATION


Leadership/Collaborating for Results/FOUNDATION

Technology/Leveraging Technology/FOUNDATION

Service/Providing Solutions to Constituent Needs/ADVANCED


We offer flexible work schedule for start and end times to accommodate personal needs. One on one training and coaching to guarantee success.

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