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Aetna Network Relations Consultant (San Diego, CA & Sacramento, CA) in Sacramento, California

Req ID: 61032BR

Job Description

Acts as the primary resource for assigned, high profile providers or groups (i.e. local, individual providers, small groups/systems) to establish, oversee, and maintain positive relationships by assisting with or responding to complex issues regarding policy related to claims, grievances, and provider data profiles.

Fundamental Components included but are not limited to:

  • Optimizes interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships.

  • Monitors service capabilities and collaborates cross-functionally to ensure that the needs of constituents are met and that escalated issues related but not limited to, claims payment, contract interpretation or parameters, and accuracy of provider contract or demographic information are resolved.

  • Supports or assists with operational activities that may include, but are not limited to, database management, and contract coordination. Performs credentialing support activities as needed.

  • Educates providers as needed to ensure compliance with contract policies and parameters, plan design, compensation process, technology, policies, and procedures.

  • Meets with key providers periodically to ensure service levels are meeting expectations.

  • Manages the development of agenda, validates materials, and facilitates external provider meetings.

  • May collaborate cross-functionally on the implementation of large provider systems, to manage cost drivers and execute specific cost initiatives to support business objectives and to identify trends and enlist assistance in problem resolution.

  • May provide guidance and training to less experienced team members.

Qualifications Requirements and Preferences:

  • 3+ years' experience in Medi-Cal managed care environment servicing providers with exposure to benefits and/or contract interpretation.

  • 3-5 years' experience with Medi-Cal managed care specific policy, benefits, plan design and language.

  • Strong verbal and written communication, interpersonal, problem resolution and critical thinking skills.

  • Working knowledge of business segment specific codes, products, and terminology.

  • Bachelor s Degree or equivalent combination of education and experience.

Functional Skills:

Administration / Operation - Document production & distribution, Claim - Policies & procedures, Communication - Provider communications

Required Skills:

General Business - Communicating for Impact, Service - Creating a Differentiated Service Experience, Service - Demonstrating Service Discipline, Service - Providing Solutions to Constituent Needs

Desired Skills:

Benefits Management - Interacting with Medical Professionals, Service - Creating a Differentiated Service Experience, Service - Handling Service Challenges

Benefit Eligibility

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

Job Function: Health Care

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.