3-5 years of experience
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Employment Type:
Full time
Job Category:
Health Care Provider
Provider Reimbursement Specialist (Woodland Hills)
Health Net, Inc. | Woodland Hills, California
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Job Description

Job Summary

  • Maintains relationships with physicians, hospitals, ancillary providers and Health Net's internal Provider Network Management Dept. Acts as first line contact for providers/hospitals on claims projects and other non-routine claim issues. Oversees, in conjunction with the Adjustment and New Day Unit Supervisors, resolution of project issues and is responsible to communicate final resolution to the provider/hospital or other business units and/or managers, as needed and/or as required. Assists with policy and procedure interpretation. Researches, analyzes and resolves complex problems with claims development and finalization.


Essential Duties & Responsibilities

  • Assists with complex claim issues and acts as the first line contact for providers on large projects and non-routine claim issues. Manages projects in conjunction with assigned adjusters and/or regional units for research, analysis and resolution. Responds directly to the providers with final resolution of the issues, up to and including: root cause documentation/feedback, necessary corrective action plans and/or process improvement initiatives.
  • Conducts routine periodic site visits to providers/physicians/facilities. Participates with Network Management in Joint Operating Committee (JOCs).
  • Coordinates with Provider Network and Provider Data Management for contract data corrections. Identifies and reports to Provider Network Management contracting opportunities with problematic provider contracts based on root cause analysis.
  • Interprets Health Net's Policy and Procedures as it relates to claim issues, providing interpretation and clarification on contracts and benefits. Coordinates with Provider Network Management (PNM) if unable to resolve with provider and internal departments.
  • Participates in process improvement activities working directly with the process improvement team to report root causes and facilitates corrective actions as needed. Prepares monthly reports to management to document issues, action plans, and resolutions of quality initiatives and provider relation improvement initiatives.
  • Researches and responds to Shared Risk Discrepancies from Participating Provider Groups.


  • Bachelor's degree in Health Services, Health Care/Hospital Administration, a related field or any combination of education and/or work experience providing equivalent background required.


Certification/Licensure Required

  • N/A
  • Government Clearance & US Citizenship Requirement


    Experience Required

  • Minimum of two years experience in medical claims review and/or claims appeal 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 oral and written communication skills and presentation skills required.
  • Strong analytical and problem solving skills required.
  • Demonstrated ability to deliver training and conduct meetings to varied audiences required.
  • Health Net experience preferred. In-depth product or multiple lines of business knowledge required (includes but not limited to HMO, PPO, POS, Medi-Cal, Fee for Service).
  • Extensive knowledge of ICD-9, CPT coding required.
  • Possession of reliable transportation, valid California???s driver???s license and proof of insurance required
  • Working Conditions

    • The PRS may be required to spend up to 90% of time in the field and will be based in a regional office (except for the internal PRS).
    • 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.
    • 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 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.