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Claims Examiner Lead-Ops - Supporting PC3
Health Net, Inc. | Rancho Cordova, California
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Job Description

Job Summary

  • Coordinates workflow and assists with supervision of unit staff in support of customer/provider/vendor/claim service activity. The lead reviews, analyzes, investigates and authorizes payment of group health claims within authority guidelines. Determines payment by referring to policy coverage and limits, and determines course of action. Corresponds with agents, policyholders, hospitals, doctors, attorneys and claimants. The lead will play a key role in ensuring quality and productivity goals are met by providing coaching, feedback and assistance with complex, escalated calls and claim issues. Acts as a Subject matter Expert on various committees in the department or company wide initiatives.
  • Essential Duties & Responsibilities

  • Demonstrates regular, reliable and predictable attendance.
  • Serves team members as an informational resource for responding to phone or written inquiries and problems.
  • Serves as a formal liaison between the management staff and the other team members for resolving barriers to service and providing appropriate resources and tools to team members.
  • Researches claim issues (resolves pending claims, adjustments and denials of request).
  • Assists providers with appropriate billing and authorization procedures.
  • Conducts monitoring and on job call coaching for the purpose of development and achievement of performance standards.
  • Assists the management staff in planning activities in order to meet service standards and maximize for continuation training and staff communication.
  • Assists with Team Meetings to foster communications and to keep team members informed of changes and updates.
  • Contributes recommendations for training programs and assists in developing and implementing service improvement initiatives (technology, training and materials) when needed.
  • Maintains thorough working knowledge of company-wide Health Net policies and procedures for claims processing.
  • Communicates with team members, providers, members, and brokers regarding problems and issues in order to resolve the issue in a ???win-win??? manner and to retain the customer.
  • Education

  • High School diploma or equivalent required
  • Certification/Licensure Required

  • N/A
  • Government Clearance & US Citizenship Requirement


    Experience Required

  • Five years claims experience, preferably in the healthcare field
  • Experience with computers
  • OR
  • Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
  • Knowledge, Skills & Abilities

  • Must have demonstrated the ability to assist co-workers and callers simultaneously and possess a thorough knowledge of company products and procedures
  • Familiarity with provider contracts/pricing mechanisms (i.e. discount per diem, tier, fee for service capitation)
  • Ability to work with staff at all levels and maintain effective work relationships
  • Strong analytical, communication, written skills, organizational negotiating and interpersonal skills
  • Analytical and detail aptitude necessary as well as the ability to be flexible and prioritize well in a fast-paced, team environment
  • Knowledge of reference materials including CPT, ICD-9, UB-92, HCFA, 1500, DSM IV, etc.
  • Personal computer skills and familiarity with window applications is required
  • Ability to multi-task on a regular basis
  • Must be able to work flexible hours as departmental needs dictate and at the discretion of the department head
  • Working Conditions

    • 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.

    Location: Rancho Cordova, CA


    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. (Source: 10-K)

    This company profile was created by AfterCollege and is about Health Net, Inc.. This page is not endorsed by or affiliated with Health Net, Inc.. For questions regarding company profiles, please email: care@aftercollege.com.