Aetna Business Consultant in Richmond, Virginia

Req ID: 52084BR


Serves as subject matter expert in researching and resolving provider claims issues, for a team of 14 Provider Network Consultants. Reviews, identifies root cause issue, and resolves provider claim concerns.

There is a strong preference for candidates within commuting distance of Aetna's Richmond, VA office.

Fundamental Components:

Serves as primary point of contact for a team of 14 Provider Network Consultants, for provider claims resolution.

Reviews claims that are presented to Network Consultant as denied or over/underpaid.

Determines root cause.

Identifies provider data, contract alignment, or claim submission errors that are causing the errors.

Submits projects for system fixes or claims readjustments.

Follows projects to resolution, keeping Network Consultant apprised of progress.

Works collaboratively with other internal teams to identify and resolve issues that are affecting multiple providers. Participates with Network Consultants in large provider or health system meetings as the claims subject matter expert.


5+ years experience with provider claims, both hospital and professional.

Strong understanding of correct coding, provider billing and payment methodologies.

Previous experience with Medicaid and Medicare provider billing and payment.

QNXT experience strongly preferred.

Strong computer skills, including Excel.

Demonstrated experience successfully implementing change in complex organizations.

Demonstrated leadership with training and mentoring a team.

Demonstrated relationship management skills; capacity to quickly build and maintain credible relationships at varying levels of the organization and with external customers.


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


Claims/Accredited Claim Adjuster (ACA) is desired


Functional - Claims/Claim processing - Medical - Behavioral Health/4-6 Years

Functional - Claims/Claim processing - Medical or Hospital- HMO/4-6 Years

Functional - Claims/Claims Administration - coordination of benefits (COB) verification/1-3 Years

Functional - Leadership/Act as company spokesperson to external constituents/1-3 Years


Technical - Aetna Applications/QNXT/4-6 Years/End User

Technical - Desktop Tools//1-3 Years/End User


General Business/Consulting for Solutions/ADVANCED

General Business/Applying Reasoned Judgment/MASTERY

General Business/Ensuring Project Discipline/ADVANCED


Leadership/Developing and Executing Strategy/FOUNDATION

Leadership/Driving Change/FOUNDATION


This is a highly visible position within a growing organization. Candidate will be working with an already strong team, bringing a much needed skill set to supplement the group. This role will contribute to the overall satisfaction of the participating provider network, which is a valuable asset to the organization. This will continue to position Aetna Better Health of VA as a leading Medicaid managed care plan in the Commonwealth of Virginia.

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: Management