Customer Service Representative Ii - Hampton, Va
Health Net (Norfolk/Hampton Roads, Virginia)

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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 Customer Service Representative II serves as a primary point of contact in our inbound call center for TRICARE beneficiaries, providers, claims subcontractors and HNFS management/associates providing administrative coverage or review of benefits, enrollment eligibility and resolving complex issues regarding payment/claims, referral and authorization coverage determinations. 

 

ESSENTIAL DUTIES AND RESPONSIBILITIES:  

Receives high volume of inbound calls from TRICARE beneficiaries and providers. Research and resolve beneficiary and provider issues by using a wide source of reference materials to support their decision. Telephonically assesses and/or validates provider’s ability to see beneficiary within access standards for Military Treatment Facility (MTF) enrollees. Provides appointment-scheduling services for all MTF enrollees and upon request from all MHS beneficiaries. Serves a critical role in maintaining 96% of referrals to MTF or network providers to avoid heavy financial penalties. Possesses knowledge of health care finder services and provides beneficiaries with the availability of alternate resources when a service request falls outside the TRICARE benefits. Provides basic and advanced level of benefit analysis according to TRICARE coverage guidelines and HNFS Corporate Policies and Procedures. Functions as a liaison between the beneficiary, the network providers and the medical staff of the MTF to channel appropriate services to the MTF or network providers. Initiates contract negotiations with non-network providers when alternatives do not exist.

REQUIREMENTS:

 

Education:

High School Diploma required. Two years of college or specialized training preferred.

 

Certification/License:

 

Experience:

TRICARE government programs or healthcare experience with a background in call customer service desired.

 

Knowledge, Skills & Abilities:

TRICARE government programs or healthcare experience with a background in call customer service desired. Internal candidates must receive a satisfactory score on the advancement exam. Demonstrated proficiency in spoken and written English with excellent verbal and written communication skills. Working knowledge of PC programs particularly Microsoft Excel and Word. Knowledgeable and proficient in maneuvering within a computer based authorization system, DEERS, enrollment system, and claims adjudication system. Ability to apply independent judgment and initiative in the performance of job duties with minimal supervision. Possesses knowledge of and experience with medical terminology and ICD-9 and CPT 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.