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Provider Network Administrator (Rancho Cordova)
Health Net, Inc. | Rancho Cordova, California
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Job Description

Job Summary

The Provider Network Administrator is the internal and external liaison for the Provider Network Management Department who maintains positive working relationships with participating physicians, participating physician groups (PPG’s), hospitals and/or ancillary providers within an assigned area. Responsible for daily administration and operation of the contractual provider relationships including overseeing accurate and current provider databases, providing training, education and information to providers, coordinating regulatory filings and rollouts, and researching, analyzing and resolving complex problems dealing with contract loading, division of financial responsibility interpretation, contract rate and language interpretation, appeals, grievances and eligibility.

Essential Duties & Responsibilities

  • Assures that contract is understood by the Provider and various HN divisions, and that the Provider is in compliance with contract. Monitors performance of Provider as defined or specified in the contract.  Researches, analyzes and resolves within limits of authority, issues related to contract interpretation, complex claims, benefit problems, shared risk settlements, appeals and grievances, eligibility and authorization inquiries. Responds to inquiries from Claims, Provider Services, Member Services, Provider Data Management, Sales, Contract Administration, Finance, Capitation, Legal, Credentialing and Appeals regarding the contract. Acts as a resource and provides support to various functional areas
  • Interprets Health Net’s policies and procedures. Provides interpretation and clarification on benefits, eligibility, reinsurance selection, access of care and operational and administrative obligations. Escalates recurring or critical issues, if unable to independently resolve, including but not limited to, quality of care issues, claims payment issues, access issues and operational/administrative issues to the appropriate Health Net department in a timely fashion. Assists with policy and procedure development interpretation and implementation within PNM and across departments. 
  • Manages Provider databases for current data and rates relating to Physician, PPG, Hospital and Ancillary information.  Ensures that provider directory information is accurate, current and accessible when needed by internal and external contacts. Facilitates and assist other Health Net departments with data base initiatives and is integral to compliance with OIG/OPM and other regulatory agency requirements.
  • Participates in special projects, which may include assistance on negotiations, new product development, completion of contract term sheets or contract configuration on new and/or existing contracts and PSAS reviews.
  • Assesses training needs of Provider personnel, (physician, PPG’s, Hospitals, Ancillary).  Develops, implements, and conducts appropriate training programs and/or orientations for staff of assigned Provider, including Provider front office staff training.  Coordinates and facilitates annual Joint Operating Committee Meeting, as identified, at the Provider sites and conducts Provider meetings as necessary.
  • Coordinates PPG transitions and rollouts that include coordination of transition team meetings, development maintenance of work plans (related to regulatory agencies including CMS, DHCS, DOI and DMHC filings) including PPG/Member crossover analysis for member reassignment and  report generation for Transition of care identification. Also assists with development and coordination of internal and external communication.
  • Performs other duties as assigned.


Bachelor's degree in Health Services, Health Care/Hospital Administration, or a related field.


Certification/Licensure Required




Government Clearance & US Citizenship Requirement


Experience Required

  • Three to five years progressive provider services experience
  • Health Net experience and in-depth product knowledge preferred
  • Experience in a managed health care environment with exposure to provider contracting, servicing benefits interpretation, and internal operations of provider relations function required
  • 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

  • Excellent verbal and written communication and presentation skills required
  • Strong analytical and problem solving skills required
  • Demonstrated ability to deliver training and conduct meetings to varied audiences required
  • Extensive knowledge of ICD-9 and 10 CPT coding required
  • Possession of reliable transportation, valid California's driver's license and proof of insurance required

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.
  • Constant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
  • Significant phone usage; headsets may be required.
  • Moderate travel may be required between work sites and/or out of area.
  • 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.
  • Moderate walking/standing may be required. Walking and/or transporting supplies and equipment between buildings/parking lots and structures may be required.



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










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)

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