Aetna Negotiator Analyst in Amherst, New York
Req ID: 60342BR
Primary purpose of this position is to lead and manage the mission of obtaining the highest possible success rates and reductions on provider claims/bills, which result in savings to both the client and the insured.
Fundamental Components included but are not limited to:
Reviews inpatient, outpatient and professional claims/bills with pre-established dollar thresholds to determine negotiation strategy and potential savings. Capability to work in a production environment reviewing and negotiating 25-40 incoming claims/bills per day, on a daily basis. Utilizes manager and experienced negotiators to develop dialogue, persuasive delivery, and approach to ensure successful negotiations. Organizes and prioritizes incoming claims/bills to ensure client criteria are maintained (example: turnaround time) and established internal goals are met. Works with all departments to obtain information such as plan benefits and insured liability, to assist in the negotiation process. Handles phone and written inquiries from providers related to pre and post negotiations. Investigates and resolves issues surrounding pre and post negotiated claims/bills. Reviews provider and claim history to assist in determining appropriate percentage reduction for negotiation. Contacts provider via phone and fax as set forth under the established guidelines for claims/bills negotiations. Acquires a working knowledge of all lines of business including but not limited to Medical and Workers' Compensation. Strives to develop and maintain provider relationships. Documents system with information pertinent to claim/bill and provider. Reviews claims/bills to initiate Long Term Agreements and Master Contracts. Maintains and utilizes all resource material and systems to effectively manage job responsibilities. Independently reviews and determines resolution for claim/bill issues and concerns.
Qualifications Requirements and Preferences:
Experience in a production environment
Customer service experience very helpful with handling billing office/provider call management preferred
Negotiations or contracting experience
Coding background critical; CPC desired
Understanding of CMS standards as they relate to adjudicating claims (edits/U&C rules/Modifiers, etc)
Claim - Claim processing - Medical - Behavioral Health, Claim - Claims Administration - cost management, Clinical / Medical - Clinical claim review & coding, Management - Management - Data analysis and interpretation, Network Management - Contract negotiation
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel
Finance - Delivering Profit and Performance, Leadership - Driving Change, Service - Handling Service Challenges
Benefits Management - Interacting with Medical Professionals, Benefits Management - Shaping the Healthcare System, General Business - Consulting for Solutions
Additional Job Information:
This role has a high level of visibility due to the accurate, timely, and efficient handling of high risk, high cost, and complex medical costs/services; must be highly organized and have detail oriented analytic skills with strong written and verbal skills required
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Job Function: Claim
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.