Provider Reimbursement Specialist - Fee Schedules

Position Purpose

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.

Responsibilities

• Assists with policy and procedure interpretation.
• Researches, analyzes and resolves complex problems with claims development and finalization.
• 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 (JOC’s).
• Captures and coordinates with Provider Network Management (PNM) if unable to resolve with provider and internal departments.
• Interprets Health Net’s Policy and Procedures as it relates to claim issues, providing interpretation and clarification on contracts and benefits.
• 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.
• Performs other duties as assigned.

Requirements

• Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.
• Minimum of two years experience in medical claims review and/or claims appeal required.
• Candidates with strong claims analysis experience preferred.
• Experience with independent dispute resolution (IDR) and provider fee schedules preferred.

Qualifications

• 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.

Skills

• Strong claims analysis experience.
• Experience with independent dispute resolution (IDR) and provider fee schedules.

Pay

$56,200.00 - $101,000.00 per year

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• A flexible approach to work with remote, hybrid, field or office work schedules.