Director, Provider Relations
POSITION SUMMARY
Responsible for network/physician administrative and operational aspects of Provider Relations, including primary care physician (PCP), specialist physician (SCP), and allied health practitioner contracting, education, and day-to-day provider services for assigned geographic region.
Fundamental Components:
Assesses, develops, and organizes physician network for HMO/PPO/POS networks.
Reviews and facilitates contracting of interested providers whose services match a need for Plan access/expansion. May work with Marketing to ensure this.
Provides oversight of physician contracting for service area.
Responsible for physician retention; initial and ongoing provider servicing, and provider compliance to Plan policy; collaborates with other departments within the organization to ensure key provider reimbursement methodologies and provisions are administratively supported.
Develops and implements provider education in support of continuing provider service relationships and contract compliance.
Prepares articles for the physician newsletter, as required.
Assists in information gathering for Plan audits by NCQA, DOH, and CMS including oversight of provider office site surveys required for credentialing and re-credentialing.
Interacts with the internal departments to resolve provider billing issues.
Assures the initial provider office orientation, as well as scheduled and unscheduled visits, are periodically conducted by assigned representatives.
Leads inter-departmental teams as necessary to implement large and/or complex provider contracts accurately.
Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including, employment, termination, performance reviews, salary reviews, and disciplinary actions.
Performs other related duties as required.
Exhibits the following Manager Behaviors
BACKGROUND/EXPERIENCE desired:
Minimum of 7 years recent and related experience in managed care.
Recent and related experience in provider contracting and provider office practices.
Strong communication, negotiation, and presentation skills.
Ability to lead professionals and manage through influence and cooperation.
EDUCATION
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
FUNCTIONAL EXPERIENCES
Functional - Management/Management - Network Management/4-6 Years
Functional - Network Management/Provider relations/7-10 Years
Functional_Experience/Functional_Focus/7-10 Years
Functional - Claims/Payment management/4-6 Years
Functional - Network Management/Credentialing/7-10 Years
TECHNOLOGY EXPERIENCES
Technical - Desktop Tools/Microsoft PowerPoint/4-6 Years/End User
Technical - Desktop Tools/Microsoft Word/4-6 Years/End User
Technical - Database/SQL Server/1-3 Years/End User
Technical - Desktop Tools/Microsoft SharePoint/4-6 Years/Administrator
ADDITIONAL JOB INFORMATION
1. Ability to develop and execute a Provider Service Strategy
2. Professional growth opportunity
3. Ability to positively impact provider and member experiences with ABH-MI
4. Ability to work with cross functional teams and varied projects beyond day to day servicing model
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.
Employment Type Regular Career Band Description Management
. Apply now!Estimated Salary: $20 to $28 per hour based on qualifications.
Responsible for network/physician administrative and operational aspects of Provider Relations, including primary care physician (PCP), specialist physician (SCP), and allied health practitioner contracting, education, and day-to-day provider services for assigned geographic region.
Fundamental Components:
Assesses, develops, and organizes physician network for HMO/PPO/POS networks.
Reviews and facilitates contracting of interested providers whose services match a need for Plan access/expansion. May work with Marketing to ensure this.
Provides oversight of physician contracting for service area.
Responsible for physician retention; initial and ongoing provider servicing, and provider compliance to Plan policy; collaborates with other departments within the organization to ensure key provider reimbursement methodologies and provisions are administratively supported.
Develops and implements provider education in support of continuing provider service relationships and contract compliance.
Prepares articles for the physician newsletter, as required.
Assists in information gathering for Plan audits by NCQA, DOH, and CMS including oversight of provider office site surveys required for credentialing and re-credentialing.
Interacts with the internal departments to resolve provider billing issues.
Assures the initial provider office orientation, as well as scheduled and unscheduled visits, are periodically conducted by assigned representatives.
Leads inter-departmental teams as necessary to implement large and/or complex provider contracts accurately.
Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including, employment, termination, performance reviews, salary reviews, and disciplinary actions.
Performs other related duties as required.
Exhibits the following Manager Behaviors
BACKGROUND/EXPERIENCE desired:
Minimum of 7 years recent and related experience in managed care.
Recent and related experience in provider contracting and provider office practices.
Strong communication, negotiation, and presentation skills.
Ability to lead professionals and manage through influence and cooperation.
EDUCATION
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
FUNCTIONAL EXPERIENCES
Functional - Management/Management - Network Management/4-6 Years
Functional - Network Management/Provider relations/7-10 Years
Functional_Experience/Functional_Focus/7-10 Years
Functional - Claims/Payment management/4-6 Years
Functional - Network Management/Credentialing/7-10 Years
TECHNOLOGY EXPERIENCES
Technical - Desktop Tools/Microsoft PowerPoint/4-6 Years/End User
Technical - Desktop Tools/Microsoft Word/4-6 Years/End User
Technical - Database/SQL Server/1-3 Years/End User
Technical - Desktop Tools/Microsoft SharePoint/4-6 Years/Administrator
ADDITIONAL JOB INFORMATION
1. Ability to develop and execute a Provider Service Strategy
2. Professional growth opportunity
3. Ability to positively impact provider and member experiences with ABH-MI
4. Ability to work with cross functional teams and varied projects beyond day to day servicing model
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.
Employment Type Regular Career Band Description Management
. Apply now!Estimated Salary: $20 to $28 per hour based on qualifications.
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