Aetna KS MCD Manager, Provider Relations (51773BR) in Overland Park, Kansas

Req ID: 51773BR


Design, develop, contract, maintain and enhance relationships with facilities, physicians and ancillary providers which serve as contractual networks of care for members; foster growth of managed care products; and enhance profitability of Aetna. Manages the day-to-day activities of the Provider Relations Department. Oversees the maintenance of working relationships with the existing network, and assists in the recruitment of new providers. Develops processes to collect and maintain accurate and current provider databases relating to provider facilities and physician information. Assists in the development of policies and procedures. Develops and implements training programs and educational materials for providers as well as internal staff.

Fundamental Components:

Responsible for provider services, provider relations, provider payment issues, and provider education.

Responsible for development and execution of provider training as stipulated in KanCare Contract.

Acts as single point of contact for KanCare to address escalated provider issues.

Provides direction to operations regarding policy and procedures related to claims/providers.

Manages a team of Provider Relations Representatives who ensure the provider data entered into the provider database is accurate and the provider documentation is complete and accurate.

Facilitates Provider Advisory Group meetings and works with management to implement suggested changes.

Works with Quality Management to develop appropriate provider measures and implement those measures in the provider community.

Develops provider communications including provider newsletters.

Develops and implements provider satisfaction surveys and uses results to manage relationships and educate staff.

Provides service to providers by resolving problems and advising providers of new protocols, policies, and procedures.

Negotiates, reviews, and prepares draft agreements with alternative delivery system facilities, laboratories, and group practices..

Manages the development and monitoring of provider contracts.

Resolves administrative problems affecting network providers, patients, and Plans within contracted guidelines.

Researches and coordinates the resolution of providers claims and capitation issues.

Coordinates provider status information with member services and other internal departments.

Hires staff, develops, and motivates staff. Initiates and communicates a variety of personnel actions including, employment, termination, performance reviews, salary reviews, and disciplinary actions.


Minimum of 5 years recent and related experience in benefits interpretation and provider networking. Minimum of 5 years recent and related management/supervisory experience with exempt level staff. Knowledge of ICD-10 and CPT codes desired. Excellent analytical and problem solving skills. Strong communication, negotiation, and presentation skills. Undergraduate degree in a closely-related field or an equivalent combination of formal education and recent, related experience. Minimum of 5 years claims experience is a must. Phone metrics experience is desired. Claims resolution experience is desired.


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


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Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Kansas is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you will join a team dedicated to improving the lives of KanCare members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Kansas, and we will support you all the way.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