Health Net, Inc. is a publicly traded managed care organization that delivers managed health care services through health plans and government-sponsored managed care plans. Its mission is to help people be healthy, secure and comfortable. Health Net, through its subsidiaries, provides and administers health benefits to approximately 5.4 million individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as "Part D"), Medicaid, U.S. Department of Defense, including TRICARE, and Veterans Affairs programs. Health Net's behavioral health services subsidiary, Managed Health Network, Inc., provides behavioral health, substance abuse and employee assistance programs to approximately 4.9 million individuals, including Health Net's own health plan members. Health Net's subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs.
For more information on Health Net, Inc., please visit the company's website at
The Claims Adjuster I researches adjustment request on previously adjudicated claims for multiple product lines.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Researches/adjusts all requests for overpayment, underpayment, refund, and contract issues to ensure compliance with departmental and company policies and procedures. Conducts cost containment analyses.
- Processes all adjustment issues, as they occur to comply with company service standards and to ensure achievement of company goals.
- Determines level of reimbursement based on established criteria: contracts, plans, and employer groups. Coordinates special payment agreements with providers based on contract terms.
- Maintains/updates knowledge of all claims products, contracts and standard reference materials.
- Develops/maintains effective business relationships with internal and external clients.
- Ensures compliance with government regulations and requirements (NCQA, DOC, HCFA).
- Performs special projects as assigned.
High School Diploma or equivalent
Two years managed care industry experience or one year single product and one year multiple product experience
Knowledge, Skills & Abilities:
- Ability to operate PC based software programs or automated database management systems preferred
- Proficiency in interpretation and application of service/legal contracts required
- Excellent written and oral communication skills, and analytical skills required
- Knowledge of standard claims forms and coding used for physicians/billings, ability to read/interpret contracts, and knowledge of standard reference publications (RVS, CPT, ICD-9, and complete product and benefit coordination knowledge (COB, TPL, WC)
- Customer service skills required, including customer correspondence
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
The following section describes the general physical requirements for this position. Please note that 'constant' refers to more than 81% of time; 'significant' refers to 40-80%; and 'moderate' refers to 20-40% of the time.
Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.
- Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
- Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
- May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
- May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
- Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
- Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
- Required to have hearing ability to receive detailed information through oral communication.
- Required to have speaking ability to express or exchange ideas.
- Constant concentration may be required on various subjects by listening, reading and thinking clearly.
- Interaction with others may be required. May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions.
- Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.
- Constant computer usage including typing and/or eye strain.
- Significant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
- Moderate phone usage; headsets may be required.
- Moderate amount of time spent working in a loud office environment with frequent interruptions/distractions.
- Constant sedentary work (desk bound or seated).
- Constant reading is required via computer screen and/or bound printed materials.
Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.