Senior Implementation Manager (Pharmacy Claim Audit)

Job Description

Description: Responsible for detailed analysis, research and response to consultant/brokers as it relates to pharmacy claim, pre and post implementation audits and operational assessments. Partners with all key stakeholders (i.e., sales/service staff, consultants, plan sponsors, and other internal business units) to proactively identify and address coding issues ensuring customer expectations are consistently satisfied or exceeded.

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Fundamental Components: Conducts extensive pharmacy claim research using RxClaim, APMCAS, Aeppays, MEA, CCI, ASD, CAS and PeopleSafe. Acts as a subject matter expert as it relates to pharmacy claim adjudication and pharmacy benefits. Prepares documentation for external distribution to assist external constituents with pharmacy claim review. Collaborates with various internal departments to provide supporting information to validate claims adjudication and policies and procedures. Works in conjunction with CVSH audit department to document audit findings. Interacts with Aetna field and APM account management teams to provide validation and explanation of audit outcomes and follow up activities. Supports Rx Implementation team on assigned pre implementation audits. Participates in the quality review of the pharmacy benefits. Shares outcomes and results with consultant/brokers. Facilitates the completion of the required documents to ensure audits meet the legal guidelines and are compliant with Aetna standards. Presents and discusses audit findings and outcomes with internal and external constituents.
Background Experience: Ability to multi task and manage workload independently. Proficient in using the following systems RxClaim, APMCAS, Aeppays, MEA, CCI, ASD, CAS and PeopleSafe. Excellent verbal and written communication skills. 3 -5 years in depth knowledge of Aetna's spectrum of products, services and system capabilities. 5 years of PBM experience preferred. Experience interacting with various levels of the organization to effectively influence others and achieve optimal results. Ability to manage competing priorities in a fast paced environment. Experience with Excel, Word, and PowerPoint helpful.
Additional Job Information: In depth knowledge of department functions that is sought by others. Exercises creativity and innovation in achieving project results. Strong interpersonal communication skills using active listening and open ended questions to encourage others' points of view to influence others to achieve best practices. Strong analytical skills and innovative problem solving abilities. Negotiation and conflict resolutions skills across various levels of the organization. Attention to detail and accuracy while focusing on overall project deliverables. Effective verbal and written communication skills. Highly organized and able to quickly prioritize multiple assignments with high quality results. Required Skills: Leadership - Collaborating for Results, Service - Handling Service Challenges, Service - Providing Solutions to Constituent Needs Desired Skills: General Business - Communicating for Impact, Leadership - Anticipating and Innovating, Sales - Knowing Customers Functional Skills: Claim - Claim processing - Pharmacy, Products-Other - Aetna Pharmacy Products, Products-Other - Pharmacy, Project Management - Issue identification and analysis Technology Experience: Aetna Application - Customer Coverage Inquiry (web), Aetna Application - LaunchASD Potential Telework Position: Yes Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Candidate Privacy Information: 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.