Aetna Manager, Pharmacy Operation Claims Oversight in Kansas City, Missouri
Req ID: 44617BR
Manages business processes associated with Pharmacy Claims Adjudication, integration processes and accuracy between pharmacy and medical accumulators, claims data flows supporting client billing and reporting. Defines an strategic direction for the team related to claims and integration processes; drives planning, funding, and execution of innovative improvements to achieve KPIs, ensure a compliant regulatory outcome and a positive member experience.
Overall, the position is accountable for the oversight and success of the Pharmacy claims system operations, claims accumulator integration, and claims data exchange processes.
Develop and implement strategic business plan to achieve business goals for effective pharmacy claims processing and the integration of pharmacy claim accumulators with medical benefits.
Oversight of vendor claims/integration performance (CVSH RxClaims, ACAS and VIAAD Integration, MSO IT Claim Reject Corrections), including contract requirements and performance guarantees.
Proactively lead projects to ensure the key systems are effectively processing claims data (RxBOR, Aeppays, EDW) and integrating with medical claims; influence all non pharmacy stakeholders to ensure success; urgently resolve system issues arising that affect access to care.
Ensure all workflow and control processes and interdependencies are identified and addressed, are compliant and meeting functional, compliance, and customer experience expectations.
Drive change in order to improve operational performance results, operational effectiveness and/or systems/quality/services identify, prioritize, and obtain funding for IT project, robotic projects, or ABX initiatives.
Manages a team of professional staff, conveys department vision, and ensure resources are aligned with pharmacy strategic objectives.
6-8 years pharmacy insurance industry experience related to claims standards & measurements, technology, systems, processes.
Leadership experience setting strategic direction, team goals, and managing change that resulted in quantifiable positive outcomes.
Managed complex IT or business projects and able to quickly create solutions to system issues.
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
Functional - Claims/Claim processing - Pharmacy/4-6 Years
Functional - General Management/Process & quality improvement/7-10 Years
Functional - Management/Management - Multifunctional management: < 25 employees/4-6 Years
Functional - Project Management/Cross-functional project management/1-3 Years
Technical - Aetna Applications/Pharmacy RxSy Suite/1-3 Years/End User
General Business/Applying Reasoned Judgment/MASTERY
Leadership/Anticipating and Innovating/ADVANCED
Leadership/Developing and Executing Strategy/ADVANCED
Service/Demonstrating Service Discipline/ADVANCED
Full-Time Telework (WAH) considered; In Office required if you are in the Hartford, CT area
Considered only for current internal teleworkers (in any area)
ADDITIONAL JOB INFORMATION
Ability to communicate effectively with management.
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.
We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.
Together we will empower people to live healthier lives.
Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.
We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.
Job Function: Management