Claims Examiner II - Single

Health Net, Inc. (NYSE: HNT) is among the nation's largest publicly traded managed health care companies. Health Net's mission is to help people be healthy, secure and comfortable. The company's POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company's Web site at www.healthnet.com



JOB SUMMARY:



Under general supervision, this position evaluates routine and non-routine claims within a single product line to determine type and amount of benefits payable. Performs all authorized duties to the processing of such claims assigned, consistent with applicable policies, procedures and department guidelines.



ESSENTIAL DUTIES AND RESPONSIBILITIES: Determines level for reimbursement based on established criteria, provider contract, plan and employer group provisions. Processes all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner. Documents provider claims/billing forms to support payments/decisions. Matches authorizations to claims, and maintains current desk procedural and reference materials. Reviews appeals and complaints; researches any missing or required information. Responds by telephone or in writing to providers, members, or other company departments to process and resolve the claim issue. Identifies dual coverage, potential third party liability cases and reinsurance cases. Refers claims with COB issues to COB, TCL, WC unit for entry. Requests additional information that is relevant to HN savings/recovery. May assist in system testing, changing, analyzing and reporting of specific enhancements for assigned product line.
REQUIREMENTS


REQUIREMENTS:



Education:

High School diploma or equivalent required.



Certification/License:



Experience:

One to two years single product experience required.



Knowledge, Skills & Abilities:Ability to operate PC based software programs or automated database management systems preferred. Ability to type 50 wpm and perform 10-key by touch required. Ability to process home health claims. Strong communication skills with strong analytical and problem solving skills. Ability to self-manage in a fast paced, detail-oriented environment. Knowledge of: managed care industry; medical terminology; standard claim forms and physician billing coding; ability to read/interpret benefit contracts; standard reference materials (PDR, RVS, CPT, ICD-9); coordination of benefits. Single product knowledge required: HMO, PPO, POS, and FFS.

OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.



Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.



Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.