CVS Health Network Contract Consultant in Blue Bell, Pennsylvania
Acts as the primary resource for assigned, high profile providers or groups (i.e. local, individual providers, small groups/systems) to establish, oversee, and maintain positive relationships by assisting with or responding to complex issues regarding policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs.
Existing Aetna EE with Aetna System experience, Experience in the Behavioral Health industry is also preferred.
3 critical Success factors: -Maintains focus on quality in completing internal processes correctly and efficiently. -The ability to provide ongoing support to help resolve issues raised by providers and other internal/external constituents. -Excellent communication skills. •Interact/Working with other department to resolve issues (Medical Network, Clinical, PDS, Claims, Credentialing) •
Knowledge -Systems/programs: Included but not limited to: EPDB, SCM, AdobeSign, Provider On-Boarding tool, ASD, CAM Websites, Microsoft office applications (Access, Excel, Word)
This position will be focused on recruiting and maintaining the Aetna Behavioral Health provider network, which includes behavioral health provider groups and practitioners.
Support of the Standard Contracting effort.
Also the ability to negotiate contracts Ind/Group providers - Contracts must be negotiated in accordance with company standards in order to maintain and enhance provider networks while meeting and exceeding accessibility, quality and financial goals
Effectively negotiates contractual relationships with Behavioral Health provider groups /individuals according to prescribed guidelines (rates / credentialing guild lines)
Responsible for understanding general cost issues and initiating appropriate action
Support Network recruitment activities as well as any integration activities
Ability to review GeoAccess reports and research identify any Corrective Action Plans if necessary
Optimizes interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships.
Monitors service capabilities and collaborates cross-functionally to ensure that the needs of constituents are met and that escalated issues related but not limited to, claims payment, contract interpretation or parameters, and accuracy of provider contract or demographic information are resolved.
Supports or assists with operational activities that may include, but are not limited to, database management, and contract coordination.
Performs credentialing support activities as needed.
Educates providers as needed to ensure compliance with contract policies and parameters, plan design, compensation process, technology, policies, and procedures.
Meets with key providers periodically to ensure service levels are meeting expectations.
Manages the development of agenda, validates materials, and facilitates external provider meetings.
May collaborate cross-functionally on the implementation of large provider systems, to manage cost drivers and execute specific cost initiatives to support business objectives and to identify trends and enlist assistance in problem resolution.
Conduct standard provider recruitment, contracting, or re-contracting activities and assist with more complex contracting and discussions as needed by business segment.
May provide guidance and training to less experienced team members.
3+ years' experience in business segment environment servicing providers with exposure to benefits and/or contract interpretation. Strong verbal and written communication, interpersonal, problem resolution and critical thinking skills.
Working knowledge of business segment specific codes, products, and terminology.
Bachelor’s Degree desired or equivalent combination of education and experience.
Additional Job Information
This position exposes successful candidates to negotiations and overall knowledge for strategic based contracting. The ideal candidate will gain knowledge of the end to end business flows to ensure overall network adequacy, knowledge on medical cost drivers, and improvement opportunities to drive better outcomes.
Associate's degree or equivalent experience
Percent of Travel Required
0 - 10%
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.