The Claims Adjuster II researches complex and high dollar adjustment requests on previously adjudicated claims for multiple product lines.
Essential Duties & Responsibilities
Demonstrates regular, reliable and predictable attendance.Researches/adjusts all difficult, complex requests for overpayment, underpayment, refund, contract issues, and stop loss 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 and updates knowledge of all claims products, contracts and standard reference materials.Develops and maintains effective business relationships with internal and external clients. Negotiates in settlement of claims when necessary.Ensures compliance with government regulations and requirements (NCQA, DOC, HCFA).Performs special projects as assigned.
High School diploma or equivalent
Government Clearance & US Citizenship Requirement
Two years adjuster experience and two years managed care or related claims experienceORAny combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
Knowledge, Skills & Abilities
Ability to operate PC based software programs or automated database management systems preferredProficiency in interpretation and application of service/legal contracts requiredExcellent written and oral communication skills, as well as analytical skills requiredKnowledge of standard claims forms and coding used for physicians/billings, ability to read and interpret contracts, 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
- 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.
- 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.
DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified.
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 - Minorities/Females/Veterans/Disability
About Health Net, Inc.
Health Net, Inc. (Health Net) is an integrated managed care organization that delivers managed healthcare services through health plans and government-sponsored, managed-care plans. The Company operates and conducts its businesses through its subsidiaries. Health Net's health plans and government contracts subsidiaries provide health benefits through its health maintenance organizations (HMOs), insured preferred provider organizations (PPOs) and point-of-service (POS) plans to approximately 6.7 million individuals across the country through group, individual, Medicare, (including the Medicare prescription drug benefit commonly referred to as Part D), Medicaid, TRICARE and Veterans Affairs programs. The Company operates within two segments: Health Plan Services and Government Contracts.