As part of the NextGen Platform development team, this position will translate and configure Provider demographic features to support the many functions within the Nextgen administrative platform. This position will be responsible for identifying gaps, performing root cause analysis, as well as the development and implementation of process improvement remediation activities. Working closely with other areas of the company such as claims, network, product, legal/compliance, medical policy, and/or segment leaders will ensure the correct decisions are made when configuring provider demographic data and/or implementing improvements. Requires the ability to manage multiple projects concurrently and the ability to keep all efforts moving toward resolution in a timely manner. Review new and existing provider demographic data to determine the most effective programming methodology to facilitate accurate and consistent claim adjudication. Assist with the development of provider rules within configuration to support claims adjudication, product set up, and provider contract load. Document decisions made during configuration to use as reference for future builds. Work collaboratively with internal/external constituents on quality reviews, audits, and test plan(s) execution. Use analytics to validate data accuracy, identify potential gaps, and develop and manage implementation of corrective actions. Identifies and appropriately escalates data transaction issues that could potentially have significant contractual implications or adversely impact service levels. Complies with the laws, regulations and ethical standards that govern the business. Identifies gaps and recommends enhancements related to new and/or existing products, services and workflows based on broad view of the organization. Influences change in order to improve performance results, organization effectiveness and/or systems/quality/services. Responsible for development and implementation of new ideas that supports work/team
- Claim processing / claim resolution experience is a must have.
- Experience working with Providers Data is a must have. Enterprise Provider Database experience preferred.
- Proven track record managing projects, meeting project objectives and project due dates (strongly desired).
- Prior experience with data analytics.
- Knowledge of provider data and provider data systems.
-Prior experience with provider demographic configuration for medical (HMO, PPO, POS), vision, dental and/or voluntary benefits (preferred).
- Experience in a production environment preferred.
- Proven communication skills, both written and verbal.
- Experience collaborating across areas to gain consensus/drive towards a common goal.
- Bachelor's degree or 3-5 years related work experience.
- Technical background with system configuration a plus.
- Medicare Experience Preferred
Associate's degree or equivalent experience
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.
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