Under close supervision, this position processes routine claims within a single product line to determine type and amount of benefit payable. Performs limited duties, subject to review and approval, for the processing of such claims assigned, consistent with applicable policies, procedures and department guidelines.
Essential Duties & Responsibilities
Demonstrates regular, reliable and predictable attendance.Determines level of 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 specification. Matches authorizations to claims, 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.
High School diploma or equivalent required
Government Clearance & US Citizenship Requirement
Minimum six months claims examining experience or completion of a technical class specializing in claims processing required. Experience working with Microsoft applications is preferred.ORAny 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 systems preferredAbility to type 50 wpm and perform 10-key by touchAbility to recognize hemo/chemo codes and home health procedure codesStrong communication, analytical, and problem solving skillsAbility to self-manage in a fast-paced, detail-oriented environmentKnowledge 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 benefitsSingle product knowledge required: HMOAbility to work in an environment that requires repetitive motion such as keying, copying and scanningAbility to sit for extended periods of time
- 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.
- Constant 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 use of other equipment including: Fax, Copier, Scanner, Printer
- Moderate lifting may be required. May need to lift, carry and/or move equipment/supplies weighing up to 10 pounds, always using safe lifting techniques.
- 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.