Aetna Negotiator Analyst in Plymouth, Minnesota
Req ID: 51666BR
The Business Consultant for the Precision Benefit Services (PBS) area will report to the Director of PBS. This candidate will be responsible for managing and approving high dollar medical costs referred to PBS as well as administering bill review services. This includes, but is not limited to, escalations generated from PBS team, all internal requests, as well as external business relationships requiring such support. The candidate will also participate in developmental and strategic levels of support for Meritain business. The candidate is responsible for developing continued efficiencies around existing PBS programs, facilitating projects as required, and developing Policy and Procedures. 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. The candidate is responsible for executing their role in an exemplary fashion that respects the ethics and demands of their role where privacy and client and membership support are paramount, and is to be reinforced in their supervised programs.
§ Managing 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§ Acting as the escalation point for negotiators, carrier coordinators, and specialty program managers, and be able to step in to address the detailed level of concerns addressed or manage any disputes§ Evaluates 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 PBS programs, at a detailed level, and to negotiate, settle, or reconcile medical costs as it relates to Meritain members/clients§ Manage and report data daily, via Excel, any of the various reporting needs, while managing staff s timelines for executing timely and risk-free cost-management programs through continued development and evaluations§ Observe and enforce within PBS, a strict adherence to all necessary policies, regulatory or contractual, that place constraints or demands on claim payment as it relates to our active programs§ Establish effective and clear communication to Meritain s Client Solution 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
§ Detailed analytical medical claims background to include coding certification (CPC preferred), medical reimbursement policy, standard claim edits, usual and customary rules and standards, benchmarking, and industry standard reporting per CMS criteria§ Must have a detailed knowledge of Medicare reporting rules, fee schedules, Usual and Customary (UCR/R&C), benchmarking of medical costs, negotiating claims/contracts, and managing complex high dollar medical services in a time-sensitive and high risk environment§ Background in anatomy, physiology, pharmacology, and the basic sciences, sufficient to support the detailed review of reported medical services/supplies for managing costs for all services/supplies/drugs§ Proficiency with Microsoft Outlook products, to include, Word, Excel, Outlook, with edit and formatting skills§ Must have an advanced understanding of the Medical Claims process as it relates to Third Party Administrators, Preferred Provider Organizations (PPO), Self-Funded Group Health Plans, and ancillary areas impacted by such costs, such as brokers, clients, consultants, membership, or outside vendors, etc§ Must have a sound understanding of HIPAA privacy and security guidelines as it relates to Protected Health Information and the dissemination of such information to outside parties and management of protected information§ Must have strong organizational and interpersonal communication skills and be able to plan, schedule, and facilitate a variety of discussions with planned action items for follow-up and completion independently§ Strong analytical skills, with the ability to work under pressure, meet timelines as requested, and deliver organized summary presentations as needed, both orally and in writing§ Must be learning ongoing Policy, Industry Standards, Software, research methods, and interpretation of policy as it relates to this role and the industry s ever changing landscape, ie, new CPT releases, FDA approvals, etc § Must be adaptable to a dynamic work environment and take on added responsibilities as needed meet the team s needs which fundamentally support an efficient multi-faceted approach to Medical cost-containment § Must communicate and manage expectations while supporting a broad range of team support§ Must be able to manage all programs with a high level of effectiveness related to prioritizing, organizing, and executing success to our clients, while managing the risks.
ADDITIONAL JOB INFORMATION
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: Claim