Aetna Provider Relations Representative - Call Center (CA MCD) in San Diego, California

Req ID: 45065BR


The Provider Relations Representative Call Center position designs, develops, contracts, maintains and enhances 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.

Fundamental Components:

Creates and/or manages cooperative working relationships with providers and/or through personal visits, correspondence and telephone contact. Educates providers and Aetna staff, including: assessing needs, designing and developing training and educational materials, training appropriate audiences/customers (e.g., contractual requirements, policies and procedures, etc.), and evaluating training success and modify educational components as needed. Coordinates distribution of educational materials. Plans and coordinates meetings, seminars and conferences. Conducts ongoing analysis and refinement of provider networks to assure appropriate network composition, system maintenance. Provides recommended changes which may include RFP surveys. Implements network development and refinement strategies. Conduct sand manages ongoing audits of provider compliance with contractual obligations and plan standards; partners with quality management in identifying and reporting trends. Conducts and manages ongoing audit of provider information. Conducts and manages on-going review of contract installations; partners with quality management in identifying, analyzing and reporting on trends. Provide issue resolution and complex trouble shooting for providers. Monitors multi-year contract rate changes, determines rate adjustments and ensures rate entry into provider/contract systems. Monitors agreements containing specific time-limited provisions to ensure adherence to expiration dates. Develops base (boilerplate) contract documents working with Legal to ensure appropriate language and provisions are included for each state, incorporating appropriate state specific language as necessary. Coordinates the filing of base contract documents within each state in region. Works with local contractors and GMs to insure contracts comply with policies and guidelines and if exceptions are necessary, ensures the ability to administer those non-standard contracts. Acts as network expert by developing and participating in presentations to existing and prospective customers. Develops capitation rates, incentives, Ref Fee schedules and other compensation rates, fees, schedules or reimbursement programs. Analyzes trends and develop reports regarding utilization and quality management for PCP offices. Identify target offices and consult on utilization patterns and practice management.


-Previous provider relations experience and background desired. -Thorough knowledge of managed care business and healthcare environment. -Strong organization and communication skills. Proficiency with MS Office Suite including Outlook, WORD, Excel and must possess strong keyboard navigation skills.


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


Functional - Network Management/Provider relations/1-3 Years

Functional - Communications/Provider communications/1-3 Years

Functional - Customer Service/Customer service - transaction based environment/1-3 Years

Functional - Customer Service/Customer service - production environment/1-3 Years

Functional - Network Management/Provider data services/1-3 Years


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

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

Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User


Service/Creating a Differentiated Service Experience/ADVANCED

Service/Providing Solutions to Constituent Needs/FOUNDATION

Technology/Leveraging Technology/FOUNDATION


Benefits Management/Interacting with Medical Professionals/ADVANCED

General Business/Communicating for Impact/ADVANCED

Sales/Managing Competitive Networks/ADVANCED


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