Prov Relations Rep, Sr

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 Senior Provider Relations Representative maintains positive working relationships with Participating Physician Groups (PPGs), hospitals, and ancillary providers within assigned areas. Responsible for daily administration and operations of the Provider Network Management Department, including overseeing accurate and current provider databases, and providing training, education, and information to providers. Assists with policy and procedure interpretation, and researches, analyzes and resolves complex problems dealing with claims, appeals, grievances and eligibility. Verifies contractual rates in the system and often makes contract with affiliate networks to verify participation, rates, and specific contract language. Participates in all phases of provider recruitment and contracting including contract preparation, telephonic outreach and follow-up with providers, negotiating and securing contracts with physicians and ancillary providers for all products offered by Health Net. Acts as the Company liaison to providers, communicating Health Net’s policies and procedures.


 

ESSENTIAL DUTIES AND RESPONSIBILITIES: Assures compliance with contracts. Researches, analyzes and resolves claims, benefits, issues and authorization inquires within delegated authority.Interprets Health Net’s policies and procedures. Provides interpretation and clarification of benefits, eligibility, and access of care. Escalates recurring or critical issues as appropriate to management.Assesses training needs. Develops, implements, and conducts appropriate training programs and/or orientations for assigned provider staff.Manages provider’s database of current data relating to provider facilities, and physician information. Ensures provider directories are accurate, current and accessible when needed by internal and external contacts.Reevaluates written PPO appeal and makes recommendations to either pay additional allowance or to deny appeal.Verifies contractual rates in the system and often makes contact with affiliate Networks to verify participation, rates, specific contract language, etc.Answers incoming provider calls pertaining to PPO contractual issues.Assists in the negotiation of provider contracts. Implements agreement in an accurate and timely manner.



REQUIREMENTS:

 

Education:

Bachelor’s Degree in Health Care Administration or related field preferred.

 

Certification/License:

 

Experience:

Two years experience in contracting/negotiation setting, provider contracting preferred; or health care/medical office environment.

 

Knowledge, Skills & Abilities:Thorough understanding of Health Plan products and lines of business, as well as familiarly with basic medical contracting methodologies, and claims pricing and reimbursement strategies. Must be accurate and detail oriented. Knowledge of state and federal health care regulations, coding, medical terminology, claims processing and provider billing.

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

 

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.