Intake Rep II

Health Net, Inc. (NYSE: HNT) is among the nation’s largest publicly traded managed health care companies. Health Net’s mission is to help people be healthy, secure and comfortable. The company’s POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company’s Web site at www.healthnet.com

 

JOB SUMMARY:

 

The Intake Representative II provides administrative coverage review for benefit determinations including an advanced level of benefit analysis for unusual or nonspecific coverage determinations. Serves a critical role in maintaining 96% of referrals to MTF or network providers, avoiding HNFS financial penalties. Ensures all authorizations and referrals are completed within TRICARE access standards.  Deciphers documents from Best Value (BV) Health Care queues within the OnTrack system using judgment to associate correspondence with the appropriate previously initiated request for service or to reassign correspondence to an appropriate queue. Completes Care Coordination System (CCS) contact screen, and routes to appropriate BV department. Provides initial review and CCS entry for all authorization and referral requests received via electronic, fax or mail. Determines the clinical information needed in CCS from the provider request documents.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES: Retrieves and reviews all correspondence from OnTrack Best Value Health Care queues, associates correspondence with the appropriate previously initiated request for service or to reassign correspondence to an appropriate queue initiates the CCS contract screen and routes to the appropriate BV department queue. Provides initial review and CCS data entry for all authorization and referral requests received via electronic, fax or US mail. Provides advanced level benefit analysis according to TRICARE coverage guidelines and HNFS Corporate Policies and Procedures. Determines what clinical information from patient information is necessary for medical necessity review and creates CCS case for auto-adjudication or 1st level RN review. Generates and completes appropriate correspondence regarding approvals, factual denial determinations and additional information requests from providers. Assesses and/or validates provider’s ability to see beneficiary within the TRICARE access standards and documents appropriately, routing inadequacies to HNFS Network Contracting Department. Validates and updates beneficiary and provider demographic information for accuracy and completeness, forwarding changes to Enrollment and/or Provider Data Management Departments.



REQUIREMENTS:

 

Education:

High School diploma or equivalent; College preferred.

 

Certification/License:

 

Experience: Two years TRICARE experience with a background in computer/data entry. Experience in health care or a managed care environment desired. Internal candidates must receive a satisfactory score on the Advancement Exam.

Knowledge, Skills & Abilities:Demonstrated proficiency in spoken and written English with excellent verbal and written communication skills. Command of PC programs such as Excel, Word, and knowledgeable and proficient with a computer-based authorization system, DEERS, enrollment system, and Internet. Ability to apply independent judgment and initiative in the performance of job duties with minimal supervision. Strong knowledge of TRICARE programs, rules and regulations. Possesses knowledge of and experience with medical terminology and ICD-9 coding.

OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position. 

 

As a Government contractor, this position requires U.S. Citizenship and proof of favorable adjudication following submission of Department of Defense form SF85P or higher security. 

 

 

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 M/F/V/D.