Job Summary: The Network Operations Consultant will be providing strong support to the global direct settlement network and achieve our common purpose of “healthy; anytime, anywhere” by ensuring that our customers receive appropriate treatment at the time and location of their choosing. Support the development and deployment of operational and technology solutions to deliver fast and effective claims flows and reconciliations; and maximize cost-effectiveness with TPAs and providers.
Key Duties and Responsibilities:
Supports the development, and management of strategic Network Operations activity in alignment with broader business objectives.
Strong organisational skills to effectively 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 our provider and TPA network
Supports the creation and execution of robust control points throughout the claims journey to enable timely reconciliations.
Assist in executing TPA and Provider claim audits to manage claim costs and identify and report fraud, waste and abuse.
Works closely with TPA and Aetna Claims teams to deliver claims reconciliations as required.
Develops and maintains strong collaborative relationships within Aetna and TPA Operational teams, as well as with the Sales/Account Management teams and our business partners throughout the region.
Working closely with the HGS Vendor Manager to ensure that Aetna receive, process and pay TPA claims in an accurate and timely manner.
Reviewing the claims process to ensure that the highest quality standards are applied to the entire claims journey, from receipt of the TPA/provider claim through to payment and EOB.
Working with the claims teams to deliver change as required.
Develop, monitor and review service performance trends, recommending specific remedial actions as required.
Coordinating and resolving escalated service issues as they arise
Develops and produces route cause analysis reports for service issues identified.
Proactive trending and tracking of service 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.
Aetna Inc. is an American managed health care company, which sells traditional and consumer directed health care insurance plans and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans. Aetna offers health care, dental, pharmacy, group life, disability, and long-term care insurance and employee benefits, primarily through employer-paid (fully or partly) insurance and benefit programs, and through Medicare.