Job Description

Job Description
The Business Consultant for the Meritain Cost Management area will report to the Head of Networks and Cost Management Strategy.

This candidate will be responsible for managing and approving high dollar medical costs referred to Cost Management as well as administering bill review services.

This includes, but is not limited to, escalations generated from Cost Management team, all internal requests, as well as external business relationships requiring such support. The candidate will also participate in developmental and strategic levels of support for Meritain business.
The candidate is responsible for developing continued efficiencies around existing Meritain programs.
The candidate will be developing and on-boarding new and strategic approaches to our existing programs, while supporting all business needs which evaluate and manage the medical costs of our clients.
The candidate is responsible for executing their role in an exemplary fashion that respects the ethics and demands of their role where privacy and client and membership support are paramount, and is to be reinforced in their supervised programs.
Managing medical costs that represent potentially high-dollar, high-risk, or high-visibility concerns to our clients and their membership requiring the analysis of cost, long-term and short-, and as needed, negotiating.
Evaluates medical claim submissions with a high level of detail to support cost containment measures as identified, and create an internal network of support to create efficient resolution to high risk items
Provide consultative support for our clients as it relates to the Meritain Cost Management programs, at a detailed level, and to negotiate, settle, or reconcile medical costs as it relates to Meritain members/clients
Establish effective and clear communication to Meritains Client Solution teams to ensure an enhanced development of their clients needs to further develop those relationships for client retention purposes

Detailed analytical medical claims background to include coding certification (CPC preferred), medical reimbursement policy, and standard claim edits. Proficiency with Microsoft Outlook products, to include, Word, Excel, Outlook, with edit and formatting skills

Must have an advanced understanding of the Medical Claims process.
Must have a sound understanding of HIPAA privacy and security guidelines as it relates to Protected Health Information and the dissemination of such information to outside parties and management of protected information
Must have strong organizational and interpersonal communication skills and be able to plan, schedule, and facilitate a variety of discussions with planned action items for follow-up and completion independently
Strong analytical skills, with the ability to work under pressure, and meet timelines as requested
Must be adaptable to a dynamic work environment and take on added responsibilities as needed meet the teams needs which fundamentally support an efficient multi-faceted approach to Medical cost-containment Must communicate and manage expectations while supporting a broad range of team support
Detailed analytical medical claims background to include coding certification (CPC preferred), medical reimbursement policy, and standard claim edits. Proficiency with Microsoft Outlook products, to include, Word, Excel, Outlook, with edit and formatting skills
Must have an advanced understanding of the Medical Claims process.
Must have a sound understanding of HIPAA privacy and security guidelines as it relates to Protected Health Information and the dissemination of such information to outside parties and management of protected information
Must have strong organizational and interpersonal communication skills and be able to plan, schedule, and facilitate a variety of discussions with planned action items for follow-up and completion independently
Strong analytical skills, with the ability to work under pressure, and meet timelines as requested
Must be adaptable to a dynamic work environment and take on added responsibilities as needed meet the teams needs which fundamentally support an efficient multi-faceted approach to Medical cost-containment Must communicate and manage expectations while supporting a broad range of team support

Ideally located near a Meritain office, Hartford CT, Plymouth MN, and Amherst NY

Required Qualifications
A Bachelors degree and 2+ years experience in the HealthCare Industry (Claims/Coding/Edit Development, medical reimbursement policy development preferred)Command of Coding, standard software edits, Facility (UB) and Professional (HCFA/CMS) formatted claim submissions Negotiating claims/contracts, and managing complex high dollar medical services in a time-sensitive and high risk environmentContracting, negotiating, and reconciliation of disputes Bill review/auditing background on both facility and professional claims with strong benchmarking skillsCertification in procedural coding or an experienced medical billing/reporting or medical review background

Preferred Qualifications
Please review required qualifications above

Education
Bachelor's degree or equivalent experience

Business Overview
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.