Aetna - Dubai - Network Operations Consultant Job Group Health Care Req# 50657BR Primary Location ARE-Dubai Locations ARE-Dubai Full or Part Time Full Time Supervisory No Job Description 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 businessobjectives.
Strong organisational skills toeffectively manage their own work. Supports the effective operation of abroad spectrum of regional direct settlement healthcare facilities for allcustomer types. Supports the creation of effectiveprocesses that provide visibility of claims activities across our provider andTPA network Supports the creation and execution ofrobust control points throughout the claims journey to enable timelyreconciliations.
Assist in executing TPA andProvider claim audits to manage claim costs and identify and report fraud,waste and abuse. Works closely with TPA and Aetna Claimsteams to deliver claims reconciliations as required. Develops and maintains strongcollaborative relationships within Aetna and TPA Operational teams, as well aswith the Sales/Account Management teams and our business partners throughoutthe region.
Working closely with the HGS VendorManager to ensure that Aetna receive, process and pay TPA claims in an accurateand timely manner. Reviewing the claims process toensure that the highest quality standards are applied to the entire claimsjourney, 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 serviceperformance trends, recommending specific remedial actions as required.
Coordinating and resolvingescalated service issues as they arise Develops and produces route causeanalysis reports for service issues identified. Proactive trending and tracking ofservice issues. Attends meetings with PlanSponsors/Brokers and Providers as required.
Supports the formal complaints proceduresby managing investigations to resolution. Creates and maintains tools, jobaids, and training materials to help to resolve issues and improve servicedelivery Engages in cross-functionalprojects that support the business strategy. Assist in developing operational andtechnology solutions to facilitate timely and accurate claim submission andreconciliation.
Additional Information Applications from job seekers who require sponsorship to work in the country of the applied position are welcome and will be considered alongside all other applications.However, those that require sponsorship may not be appointed to a post if a suitably qualifed, experienced and skilled citizen of the country is available to take up the post, as the employing body is unlikely, in these circumstances, to satisfy local country immigration laws.For further information please visit the country's immigration website.
Country Name United Arab Emirates
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