Aetna Network Operations Consultant (South Africa) - 50700BR in South Africa

Req ID: 50700BR

(( Aetna Internal Applicants - Please note that we're open to Temporary secondments to South Africa for this specific role ))

Family Summary

Providing strong support to the global direct settlement network andachieve our common purpose of “healthy; anytime, anywhere by ensuring that ourcustomers receive appropriate treatment at the time and location of theirchoosing.

Support the development and deployment of operational and technologysolutions to deliver fast and effective claims flows and reconciliations; andmaximize cost-effectiveness with TPAs and providers.

Position Summary

  • Supports the development, and managementof strategic Network Operations activity in alignment with broader business objectives.

  • Strong organisational skills toeffectively manage their own work.

  • Supports the effective operation of abroad spectrum of regional direct settlement healthcare facilities for all customer types.

  • Supports the creation of effective processes that provide visibility of claims activities across the Africa provider network

  • Supports the creation and execution of robust control points throughout the claims journey to enable timely reconciliations.

  • Assist in executing claim audits to manage claim costs and identify and report fraud, waste and abuse.

  • Works closely with the Claims teams to deliver claims reconciliations as required.

  • Develops and maintains strong collaborative relationships within Aetna Operational teams, as well as with theSales/Account Management teams and our business partners throughout the region.

  • Working closely with TPA and Vendor Management to ensure that Aetna receive, process and pay claims in an accurate and timely manner.

  • Reviewing and enhancing the Africa claims process to ensure that the highest quality standards are applied to the entire claims journey, from receipt of the claim through to payment and EOB.

  • Develop, monitor and review service performance trends, recommending specific remedial actions as required.

  • Managing, coordinating and resolving escalated service issues as they arise

  • Develops and produces root cause analysis reports for service issues identified.

  • Proactive trending and tracking ofservice issues.

  • Attends meetings with Plan Sponsors/Brokers and Providers as required.

  • Supports the formal complaints procedures by managing investigations to resolution.

  • Creates and maintains tools, job aids, and training materials to help to resolve issues and improve service delivery

  • Engages in cross-functional projects that support the business strategy.

  • Assist in developing operational and technology solutions to facilitate timely and accurate claim submission and reconciliation.

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Job Function: Customer Service