Aetna Supervisor Business Consultant in Blue Bell, Pennsylvania
Req ID: 61444BR
This person will Supervise the team that processes all IRE correspondence (MAXIMUS, ALJ, MAC) as well as oversee all CMS related audits, CMS inquires, external audits, CMS reporting requirements, OMT metrics related to Part C appeals, external QA related activities related to Part C appeals, and internal monitoring for Part C Appeals operations. Independently coaches others on appeals ensuring compliance with Federal and/or State regulations. Oversee the management of IRE inventory and audit related activities. Responsible for insuring timeliness of effectuations and responses to the IRE as ensuring timely and accurate responses related to internal QA findings, corporate quality findings, CMS audits, external audits, NCQA surveys, and internal compliance related inquiries.
Responsibilities will have national scope. Familiarity with Medicare regulations. Surpasses the behaviors outlined in the Sr. Complaint & Appeal Analyst Competencies as well as Complaint & Appeal Supervisor competencies. Independently researches, translates organizational policy into intelligent and logically written and/or verbal responses internally and to external departments such as Claims, Medicare Compliance, Grievance, Customer Service for all products and issues pertaining to members or providers. Educates analysts and business units of identified issues and potential risk. Initiates and encourages open and frequent communication, between constituents, to dissect policies, trends, and workflows, in turn identifying areas in need of improvement, throughout various departments.
Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases. Considers potential risks and cost implications as an incorrect or inaccurate response and/or decision may result in additional rework, confusion to the constituents, or legal ramifications. Must have excellent knowledge on how to effectively use all tools associated with appeals and claim processing (MHK, CATS, Navigator, NexGen Systems, ECHS, ASD, EPDB, SCM, WEB CCI, Plan Sponsor Tool, AST, Claims X-ten, E-policy, IOP, and all claim processing screens). Preferred knowledge of Independent Review Entity (IRE) decisions and regulations.
Fundamental Components included but are not limited to:
Strong analytical skills with attention to detail
Power to work collaboratively across the organization both internal and external
Coaches and supports others with accuracy and ethical resolution
Knowledge of clinical terminology and regulatory requirements
Acts decisively to ensure business continuity and with awareness of all possible implications and impact
Autonomously makes decisions based upon Aetna s current policies/guidelines
Independently and accurately able to multi-task projects; ability to be self-sufficient while researching, performing analysis and applying resources necessary to complete a final assessment of the required and appropriate action (verbal and/or written)
Qualifications Requirements and Preferences:
Demonstrated relationship management skills at the senior level; capacity to quickly build and maintain credible relationships at varying levels of the organization simultaneously.
Demonstrated superior business process, project management and organizational redesign experience.
Demonstrated experience successfully implementing change in complex organizations.
Operational experience in a relevant discipline.
Bachelor's degree preferred, but not required. Appropriate licensure or certification by discipline preferred.
Claim - Claim processing - Medical - Medicare, Clinical / Medical - Legal & benefit interpretation, Communication - Employee communications, Communication - Member communications
Aetna Application - Aetna Medicare Resource Center, Aetna Application - Aetna Total clinical View
Benefits Management - Interacting with Medical Professionals, General Business - Communicating for Impact, Leadership - Collaborating for Results, Leadership - Creating Accountability
General Business - Maximizing Work Practices, General Business - Turning Data into Information, Leadership - Driving a Culture of Compliance, Service - Improving Constituent-Focused Processes
Additional Job Information:
Team leadership and team building skills.Analytical and planning skills.Negotiation/influencing skills.Relationship and change management skills.Organizational skills.Time management skills.Critical thinking skills.Oral and written communication skills.
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Job Function: Management
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.