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
Under direct supervision, the Customer Service Representative handles customer inquiries, including but not limited to claims and benefit interpretation. The Customer Service Representative services prospective members, enrolled members, providers, employers, vendors, and other Health Net customers. This position is responsible for resolving all aspects of customer inquiries and complaints, for providing accurate and timely responses, and for entering accurate information into the customer database.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Handles general inbound ACD calls, correspondence, and lobby visits related to all aspects of service. Effectively communicates, written and verbally, Health Net policies, procedures, and applicable benefits to members and/or providers who have misinterpreted, were unaware of, or are questioning a Health Net policy or decision.
- Researches claims according to established policies and procedures. Determines claim status and consults with appropriate staff and/or management on all questionable claims in order to ensure proper disposition.
- Must meet departmental standards for quality, productivity and teamwork. Communicates accurate information to customer questions and requests, by phone and/or in writing, in a courteous and professional manner. Able to handle difficult and sensitive issues appropriately; maintains highest level of customer confidentiality.
- Investigates customers' problems as indicated. Initiates appropriate action to ensure timely resolution. Interacts with staff in other departments to clarify problems presented by customers and to obtain accurate information.
- Develops and maintains a comprehensive knowledge of all Health Net policies, procedures, products and services including departmental processes of Medical Management, Network Management, Sales & Marketing and Government Programs.
- Identifies, analyzes and performs any of the following:
- Member/Provider eligibility and benefit questions and research
- Research and interpretation of claims, including all aspects of COB, NF, Worker's compensation and claim recovery
- All correspondence including internet correspondence, emergency room appeals, member and employer questionnaires, enrollment applications and Authorization Services forms
- Referrals/Authorizations research
- Facilitates filing of appeals and grievances
- Plans (including all Non-Standard Plans, ASO, and Government Programs)
- Enrollment and Eligibility
- Benefit Product comparisons, Exclusions, Limitations, and Product nuances
- Interpret Health Net remittance advices and member EOB's
- Performs data input in a highly accurate and timely fashion for all customer contacts according to the customer information database system parameters. Assures documentation is complete, so department is able to monitor physician compliance.
- Participates in various training and information functions available to the Health Plan Operations staff members to enhance skills, improve performance, and contribute to the ongoing development and achievement of departmental goals.
- Has an understanding of, and is able to communicate member benefits, reimbursement policies, coding guidelines, the appeal and grievance procedures, and company policy to all customers.
High School Diploma
Some experience in customer service or telemarketing, medical terminology, claim processing desired
Experience with HMO, insurance carrier or Third Party Administrator desired
Knowledge, Skills & Abilities:
- Must be a self-starter with a strong desire to provide superior customer service
- Computer skills and familiarity with Window applications, with typing ability of 30 wpm required
- Ability to interact professionally with both internal and external contacts
- Able to work flexible hours, including weekends and evenings, as department or training needs dictate, and at the discretion of management
- Good written, oral and interpersonal communication skills
- Ability and desire to work in a fast paced environment is required
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).
- Constant phone usage; headsets may be required.
- Constant 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.