Aetna MDCR Operations Cnslt in Santa Ana, California

Req ID: 54485BR


Designs cross-functional solutions to address business problems in the Northwest Medicare market. This work results in initiatives that significantly impact company strategy enabling Aetna to be competitive in the marketplace and effectively serve its customers. Partners with business owners to optimize the achievement of strategic business objectives, to include profitable growth and improved organizational effectiveness. (Focus includes one or more of the following disciplines: Management consulting, business process/project consulting, financial strategic analysis, mergers and acquisitions, strategic business planning, and, or risk management consulting)

Fundamental Components:

Serves as subject matter expert for the operational functions of Medicare products within an assigned market.

Assists with the execution of all CMS required activities and processes including the accuracy and compliance of the annual bid application, expansion application, member materials, and group setup.

Supports internal and external Medicare audit activity including CMS and operation integrity audits. Coordinates file pulls, data requests, universe development, and supporting documentation.

Maintains an awareness of trends, developments, and governmental regulations in Medicare and managed health care organizations.

Provides consultative support for Medicare product design features, integration schedule, and operational readiness in a new product start-up environment.

May participate on various committees to represent the Medicare Department including NCQA, Internal Research, UM/QI, Trend/MER, Risk Mitigation, Complaint and Appeals, bid, implementation, and migration.

Supports member retention activities, including development of outreach materials, design/implementation of outreach programs both directly and in coordination with corporate member retention team, development of talking points/educational pieces about market specific issues.

Monitors sales and marketing activities to assure adherence to Federal and State regulations.


Previous experience (5-7 years) in Medicare Operations and/or Medicare compliance functions.

Familiarity with regulations and statutes impacting the managed care environment.

Ability to perform analysis and legal research to identify and clarify issues.

Excellent consulting and leadership skills.

Excellent communication, interpersonal and presentation skills.

Able to effectively coordinate multiple projects and programs in a matrix environment and work independently.


The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.


Functional - Sales & Service/Account Management/1-3 Years

Functional - Communications/Member communications/1-3 Years

Functional - Products-Medical/Individual Medicare Advantage Plan/1-3 Years

Functional - Leadership/Lead a major product launch/1-3 Years


Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User

Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/End User


General Business/Managing Sales Relationships/ADVANCED

Sales/Selling Products and Services/FOUNDATION

Service/Case Administration/FOUNDATION


Leadership/Collaborating for Results/FOUNDATION

Leadership/Driving a Culture of Compliance/FOUNDATION

Sales/Knowing Customers/FOUNDATION

Telework-Open to any location in the Western/Northwest Region. Wa., ID, OR., Ca.


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 candidates'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

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.