Manager Appeals: Medicaid

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:



This Managerial position is specialized in Medicaid Appeals and Grievances for CT and NJ. This position is responsible for understanding and ensuring compliance with a highly regulated appeals and grievances process that has regulation and accrediting criteria for one or various state and federal bodies, including department of managed health care, center for Medicare and/or Medicaid services, Knox-Keene, various state departments of insurance agencies, national committee for quality assurance, among others Failure to meet regulations could result in significant financial penalties and sanctions, as well as licensure revocation.



ESSENTIAL DUTIES AND RESPONSIBILITIES: Recruits, coordinates training of, and supervises grievance specialists, clinical appeals and/or intake specialists.Ensures consistent compliance with all state and federal requirements related to appeals and grievances, including timeliness, accurate communication and adherence to standards. Directs the daily work performed on all member, provider appeals and grievances.Maintains comprehensive knowledge of all Health Net products and the Health Net's Purchase Service Agreements with correspondent State Department of Social Services (DSS) and correspondent State Division of Medical Assistance and Health Services (DMAHS), if applicable. Maintains a comprehensive knowledge of departmental and company policies, procedures, and services, including departmental processes of Operations, Medical Management, Customer Service, Sales and Marketing, Government and State Health Programs, Network Management, and regional offices.Ensures that the turnaround time on resolving all appeals and grievances remains within regulatory requirements.Meets the performance (carrier) guarantees set forth by specific employer groups enrolled in Health Net. Coordinates appeal and grievance processes and reporting to positively impact process integrity. Works closely with clinical staff on cases that fall between medical and non-medical necessity issues to ensure that all appeals and grievances are handled appropriately and responded to within appropriate timeframes.Works with Health Net associates and other departmental managers to develop training modules and online help desk information and scripting related to the appeal and grievance processes.
REQUIREMENTS


REQUIREMENTS:




Education:
Bachelor's Degree



Certification/License:



Experience:Minimum five years customer service experience and one year supervisory experience OR equivalent business experiences are requiredManaged Health Care/Insurance experience is highly desirable

Knowledge, Skills & Abilities:Excellent interpersonal, negotiating and writing skills are requiredAbility to manage difficult and sensitive customer issues is essentialBasic PC skills necessary, preferably in a Windows environmentAbility to type a minimum of 40 wpm

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.