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Senior Consultant - Provider Data Services - Configuration/Research

Company: Aetna Inc.
Location: Kenner
Posted on: June 4, 2021

Job Description:

Job Description

Provides consultation on the design, testing and enhancement of claim and contract configuration setup including technical support to external providers and internal customers. Researches, manipulates and prepares complex data to document program activities and reports on its results.Provides oversight to data quality and provides feedback to various areas in order to improve service delivery and enhancement to data configuration efforts. Develops a consultative relationship with external providers and internal customers.

  • May lead or act as a business technical expert with the planning, development and validation of master or detail test claims andstrategies.
  • Performs ongoing research, and support tasks for existing claims and contract configuration.

Acts as a business technical consultant in the design of new applications or enhancements including integration of solutions.

  • Provides Leadership/Coaching/Mentoring; may be a mentor to others.
  • Directs the implementation of program specific information through provider education, technology, organizational methods and procedures.
  • Influences enhancements to business processes and system infrastructure to improve data quality availability and access.
  • Manages customer contact and participates in internal and external health industry development efforts (e.g., claims performance measurements).
  • Analyzes complex data for trends, highlights in-depth interpretations and provides in-depth root cause analysis.
  • Consults with provider on a regular basis to ensure progress is in line with provider's expectations and to obtain additional information as needed.
  • Translates complex claim data into constructive data and information and makes recommendations.
  • Defines, identifies, develops and implements information products to support strategic business and operational planning.
  • Illustrates complex information in a clear concise manner.
  • Develops and conducts presentations and consultations to existing and prospective providers and internal business areas.
  • Provides workgroup support on projects Influences changes/enhancements to business processes, policies, and system infrastructure to improve information quality, availability and access.
  • Promotes and educate providers on cultural competency
  • Interprets contractual requirements including federal and state regulations and NCQA.
  • Independent resolution of claim problems. Assist others with resolution of problems involving research into both provider and regulator policy data.
  • Assist with analyzing and the resolution of error situations that require system research; such as claim audit results.
  • Reviews all management level claim reports for validity, accuracy and trends.
  • Ensures internal as well as external financial transactions associated with unit functions are appropriately applied.
  • Monitors and reviews designated claims system activity and proactively leads investigation of discrepancies and trend fluctuations.
  • Conducts peer to peer training on claim systems and service functions for new and existing staff. Makes presentations to peers and customers (internal and external).

Required Qualifications

  • Excellent verbal and written communication skills.
  • Extensive experience with databases as well interpretation and manipulation of related data.
  • Healthcare background.
  • 3-5 years of data interpretation and analysis experience.
  • Bachelor's degree, technical certification or equivalent work experience.

Preferred Qualifications

Please review required qualifications above

Education

Bachelor's degree or equivalent experience

Business Overview

At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

Keywords: Aetna Inc., Kenner , Senior Consultant - Provider Data Services - Configuration/Research, Other , Kenner, Louisiana

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