Clinical Claim Review Specialist I

About Moda Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together. Let’s do great things, together! About Moda Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together. Job Summary Provides support to the Medical Management team by assisting in the reviewing, researching and triaging of post service claim. Knowledgeable of utilization review processes, turnaround times, and concurrent review processes when reviewing, preparing or completing retrospective reviews. This is a FT WFH position. Pay Range $19.43 - $21.86 hourly (depending on experience). Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range Benefits Medical, Dental, Vision, Pharmacy, Life, & Disability 401K- Matching FSA Employee Assistance Program PTO and Company Paid Holidays Primary Functions Researches and triages claims routed to Healthcare Services based on guidelines. Determines if the plan type, ICD-10 code and CPT/HCPC code or place of service listed on the claim requires an authorization. Interacts with providers and provider offices to gather complete medical records information necessary for review of claim. Consults the RN or Supervisor on complex cases. Utilizes the Moda Health core systems for documentation of contact with providers and members. Communicates effectively with other Medical Management support staff. Analyze claims and encounters according to the limits of authorization, benefit plan and provider contracts. Effectively uses the Moda Health core systems to accurately determine eligibility, benefit plan, and physician networks associated with the member’s plan. Send proper correspondence to providers, members and other departments to obtain additional information necessary for the review of claims. Analyze authorizations for correct information, such as authorization maximums, limitations and special instructions for performance groups. Ensure adherence of Health Insurance Portability and Accountability Act (HIPPA) and other regulatory guidelines including privacy and security. Must maintain minimum production and quality audit. Responsible for the auditing of individual daily work for accuracy, consistency and compliance based on Moda Health policies and procedures, state, federal and CMS (Medicare) regulations. Identifies problems and researches alternative solutions. Perform data entry of authorizations/referrals received via fax. Enter data into Facets UM, must be able to accurately determine member eligibility and provider participation within a network Completes other duties and special projects as assigned by the HCS Claims Supervisor and/or the HCS Manager. Other duties as assigned. Required Skills & Experience High school education or equivalent. 2 - 4 years’ experience in a medical office and/or insurance experience preferred. Proficient in Microsoft Office applications. Type a minimum of 35 wpm and 10key proficiency of 135spm on computer number keypad. Excellent written, verbal and interpersonal communication skills including demonstrated business writing and grammar skills. Excellent organizational and detail orientation skills with a proven ability to multi-task and switch between phone work, fax work and research with ease. Must present a professional business image in all settings. Ability to work well under pressure, work with frequent interruptions and shifting priorities. Ability to come to work on time and on a daily basis. Ability to work independently, as well as part of a team, dealing with all levels of staff, members, providers, in a professional manner. Ability to maintain confidentiality. Knowledge of medical terminology and coding PC literacy Knowledge of Health Plan benefits. Ability to interpret complex benefit packages and contract language Strong problem solving and decision-making skills Familiar with CMS (Medicare) rules and regulations a plus but not required. Working Conditions & Contact With Others Extensive close PC work, constant sitting, extensive keyboard work and frequent phone work. Constant shifting of priorities and day-to-day duties. Work in excess of standard work week during peak business periods. Internally with multiple departments. Externally with provider offices, hospitals and members. Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. For more information regarding accommodations please direct your questions to Kristy Nehler and Danielle Baker via our View email address on click.appcast.io email. #J-18808-Ljbffr Moda Health