Aetna Business Consultant in Hartford, Connecticut

Req ID: 53915BR


The Business Consultant for the Meritain Cost Management area will report to the Head of Network and Cost Management. This candidate will be responsible for managing high dollar medical costs referred to Cost Management as well as administering bill review services. The candidate will also participate in developmental and strategic levels of support for Meritain business. The candidate will be managing and updating direct provider contracts, developing and on-boarding new and strategic approaches to our existing programs, while supporting all business needs which evaluate and manage the medical costs of our clients.

Fundamental Components:

*Manage medical costs that represent potentially high-dollar, high-risk, or high-visibility concerns to our clients and their membership requiring the analysis of cost, long-term and short-, and as needed, negotiating


*Evaluate medical claim submissions with a high level of detail to support cost containment measures as identified, and create an internal network of support to create efficient resolution to high risk items


*Provide consultative support for our clients as it relates to the Meritain Cost Management programs, at a detailed level, and to negotiate, settle, or reconcile medical costs as it relates to Meritain members/clients


*Establish effective and clear communication to Meritains Client Management teams to ensure an enhanced development of their clients needs to further develop those relationships for client retention purposes


*Independently access necessary resources to formulate decision-making as it relates to carrier-related cost-containment through interaction of Claims area, Stop Loss, Client Relations, Quality Assurance, etc


*5+ years experience in the HealthCare Industry (Claims/Coding/Edit Development, medical reimbursement policy development preferred), and one or more of the following methodologies: financial strategic analysis, strategic business planning, and/or risk management consulting.


*Command of Coding, Medicare edits, standard software edits, Facility (UB) and Professional (HCFA/CMS) formatted claim submissions


*Contracting, negotiating, and reconciliation of disputes with interpersonal management of risk


*Data Management skills with ability to evaluate, as well as generate, reports as needed to define a targeted needan analytical and statistical background is desired


*Project work, or Business Analysis backgrounds with recognized teamwork skills and demonstrated success


*Familiarity with Fraud, Waste and Abuse schemes within the HealthCare Industry


*Certification in procedural coding or an experienced medical billing/reporting or medical review background


The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.


medical management/AMA Certificate - Procedural Coding and Reporting is desired


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.

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Job Function: Management

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.