Aetna VA MCD Bus Project Program Mgr in Richmond, Virginia

Req ID: 51190BR

Position Summary:

This position reports to the COO and will serve as a SME for claims, billing, coding and other claims related work/tasks. Supports the business by recommending appropriate actions, strategies and/or alternatives to meet business needs. Has responsibility for leading/managing all aspects of a project and or program such as planning, coordination, development, implementation including the financial implications while prioritizing work, resources and time. Ensures the end state of the project and/or business operations meets business objective(s) and that all deliverables and due dates are met. Highly collaborative process often requires managing relationships across the segments or multiple functional areas.

Job Responsibilties:

Develops and implements strategic business plan to achieve business goals.

Analyzes claims data to search for claims that have been paid/denied incorrectly.

Actively researches and understands contract terms.

Proactively leads complex projects by setting strategic direction.

Identifies gaps and recommends enhancements related to new and/or existing products, services and workflows based on broad view of the organization.

Collaborates and partners with other functional managers, other business areas across/within segments or other business areas to ensure all workflow processes and interdependencies are identified and addressed.

Consults with constituents (these may be internal and/or external) to scope/define project.

Influences change in order to improve performance results, organization effectiveness and/or systems/quality/services.

Obtains financial support for most complex projects or supports this work as it relates to program management.

Collaboratively works across multiple functions and /or segments to obtain agreement from all impacted parties (e.g., up and downstream effects often impact multiple functions and/or segments.

Responsible for development and implementation of new ideas that supports work/team.

Cross function/segment group facilitation/presentation.

Leads all project and/or program management work including monitoring and tracking of progress and status update communications.

Responsible for resource utilization within and across work teams.

Responsible for the financial implications of projects and/or program budgets.

Assists others to identify solutions to issues that negatively impact program and/or project plan.

Background/Experience Desired:

Bachelors degree or equivalent work experience is required; 5-7 years claims processing experience required; knowledgeable in proper billing procedures, coding, and editing, is required; project management skills required; demonstrated experience as an expert in understanding claims processing is required; a certified coder is strongly preferred. Demonstrated ability to analyze claims and understand complex documents and contract terms.


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

Functional Experiences:

Functional - Claims/Claim processing - Medical - Medicare/4-6 Years

Functional - Claims/Claim processing - Medical - Behavioral Health/4-6 Years

Functional - Claims/Claims Administration - cost management/4-6 Years

Functional - Clinical / Medical/Clinical claim review & coding/4-6 Years

Functional - Claims/Payment Management/4-6 Years

Technology Experiences:

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

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

Technical - Aetna Applications/QNXT/4-6 Years/End User

Additional Job Information:

Demonstrated proficiency with MS Office Suite(Word, Excel, Sharepoint, Outlook) and other Aetna applications including QNXT; strong keyboard navigation skills.

Exceptional communication (verbal, written, presentation), organization and time management skills are required.

Minimal travel may be required.

Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you'll join a team dedicated to improving the lives of Virginia Medicaid members. Our vision incorporates community-based health care that works. Align your career goals with Aetna Better Health of Virginia, and we will support you all the way.

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. 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.

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.

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: Management