Aetna Sr Provider Relations Rep Oversight (CA MCD) in San Diego, California

Req ID: 44386BR


The Sr. Provider Relations Oversight Representative is responsible for maintaining working relationships with the existing provider network. Assists providers with policy and procedure interpretation. Maintains accurate and current databases relating to provider facilities and physician information. Assists with physician recruitment.

We are hiring 2 in San Diego and 2 in Sacramento. Candidates must be co-located in either city, able to travel in and around the territory.

Fundamental Components:

  • Maintains regular contact with key provider organizations and serves as a liaison to internally resolve complex issues; develops strong interpersonal relationships with assigned providers.

-Assists in facilitating Provider Advisory group meetings.

-Develops provider communications and newsletters observing department guidelines.

-Resolves administrative problems impacting network providers, patients and health plan within contract guidelines.

-Researches and coordinates the resolution of provider's claims and capitation issues.

-Coordinates provider status information with member services and other internal departments.

  • Researches and resolves incoming escalated provider inquiries within contract guidelines; educates providers on new protocols, policies, and procedures.

-Assists with physician recruitment by identifying specific providers within a designated territory, facilitating the distribution of provider agreements, negotiating rates for new physicians, and renegotiating contracts for existing physicians within established limits.

-Conducts provider office site visits as necessary to ensure site meets contract guidelines.

-Provides assistance to less experienced Provider Relations Representatives to help resolve complex provider issues; serves as subject matter expert to other department staff.

-Ensures provider database and documentation is up-to-date, accurate, and complete; ensures new physician contracts are entered promptly and accurately.

-Assists with the development and implementation of provider training programs.

-Serves as a training resource and mentor to Provider Relations Representatives; identifies and shares best practices.

-Analyzes changing business requirements; makes recommendations to management for process improvements as required.

-Performs other related duties as required.


(*) Minimum of 5 years recent and related customer service experience with exposure to benefits interpretation and provider networking.

(*) Minimum of 3 years recent and related experience as a Provider Relations Representative.

(*) Experience in managed care policy and direction, benefit plan design, and provider fee schedules desired, but not required.

(*) Knowledge of ICD-9 and CPT codes desired.


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


Functional - Network Management/Provider relations/4-6 Years

Functional - Network Management/Provider data services/4-6 Years


Technical - Desktop Tools/Microsoft Word/4-6 Years/End User

Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/End User

Technical - Desktop Tools/Microsoft PowerPoint/4-6 Years/End User

Telework Specifications:

Initially office based with potential to telecommute.


Education and Certification Requirements: Bachelor's degree in a closely-related field, or equivalent combination of education and experience. Strong organizational, communication and prioritization skills. Must possess critical thinking skills and ability to interact with all levels of management. Demonstrated proficiency with MS Office Suite, keyboard navigation skills, demonstrated ability to navigating other systems and applications.

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