Health Net, Inc.
Position Purpose: Process pended medical claims, verifying and updating information on submitted claims and reviewing work processes to determine reimbursement eligibility. Ensure payments and/or denials are made in accordance with company practices and procedures.
Apply policy and provider contract provisions to determine if claim is payable, if additional information is needed, or if claim should be denied. Claims processing may be related to physician and hospital services, coordination of benefits (COB), high dollar, special pricing, refunds and/or adjustments on resubmitted claims.
Research and determine status of medical related claims
Review charges, access the computer system and use payment or denial codes within established department guidelines and standards
Clarify health insurance coverage for coordination of benefits to process claims
Maintain records, files, and documentation as appropriate
Meet department production and quality standards
Education/Experience: High school diploma or equivalent. 1+ years of claims processing, medical billing, administrative, customer service, call center, or physician’s office or other office services experience. Experience operating a 10-key calculator and computers. Ability to perform basic math functions and reason logically. Working knowledge of ICD-9, CPT, HCPCs, revenue codes, and medical terminology preferred. Experience with Medicaid or Medicare claims preferred.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
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