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Aetna Credentialing Analyst in Charleston, West Virginia

Req ID: 65921BR

Job Description

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

Fundamental Components included but are not limited to:

  • Maintains high production and quality factors.

  • Participates in development of credentialing processes and workflows.

  • Identifies improvement opportunities and recommends enhancements and workable solutions.

  • Provides telephonic education to providers/producers on credentialing policies and procedures.

  • Identifies and communicates trends (quality of results, efficiencies of processes).

  • Researches and prepares risk sensitive or complex business review/credentialing verification items for CPC. Reviews completed investigative files of co-workers for completion and accuracy.

  • Manages vendor on-line access of primary verification sources.

  • Provides ongoing support to department members in completing research and analysis to resolve complex issues raised by providers/producers and other internal/external customers.

  • Directly contacts providers/producers and/or outside entities to clarify data quality issues.

  • Provides issue resolution for providers/producers, during the credentialing or data management processes. Responds to network or provider/producer inquiries, including contracting and credentialing policy, procedures, credentialing status.

  • Perform data entry and systems maintenance as needed; align data across systems.

  • Ongoing License Sanction monitoring and reporting to minimize corporate risk.

Qualifications Requirements and Preferences:

  • Track record of prioritizing work, multi-tasking, and managing workload efficiently.

  • College degree or equivalent work experience preferred.

  • High School Diploma or G.E.D.

Technology Experience:

Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Required Skills:

Service - Creating a Differentiated Service Experience, Service - Demonstrating Service Discipline

Benefit Eligibility

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Job Function: Healthcare

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.