Medical Claims Support I

Job Description

Job Description

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.

Position Summary
Investigates and processes claim adjustments for all medical lines of business and COB claim adjustments for Medicare/Medicaid plans. Also processes adjustments related to overpayment recovery, underpayment adjustments and other corrections. Performs COB updates (excluding Commercial), file reviews, issues adjustment related letters to members and providers, performs payment offsets and also validates and completes stop payment requests. Assists in customer service inquiries regarding contractual and administrative policies and applies excellent customer service when a phone call is needed to complete an adjustment or other support work. This is a FT WFH role.

Pay Range
$21.30 - $23.96 hourly, DOE.
*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.

Please fill out an application on our company page, linked below, to be considered for this position.
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Benefits:

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education:

1. High School diploma or equivalent.
2. Minimum of 6 months medical claim processing or customer service dealing with all types of plans/claims and consistently exceeding performance levels
3. At least 12 months experience as a Processor I and consistently performing at an exceeding level of performance. Support Processor I designation may also be obtained through equivalent work experience and knowledge level at Moda Health or when recruiting externally.
4. Professional and effective written and verbal communication skills
5. 10-key proficiency of 135 wpm net on a computer numeric keypad.
6. Type a minimum of 35 wpm net on a computer keyboard.
7. Ability to show a pattern of maintaining balanced performance, which consistently exceeds expectations in areas of production and quality.
8. Strong and proficient organizational abilities and the ability to handle a variety of functions
9. Ability to efficiently multitask and work well under pressure and meet timelines.
10. Ability to maintain confidentiality internally and externally and project a professional business image always.
11. Strong analytical, problem solving, decision making and detail-oriented skills with ability to shift priorities as needed.
12. Strong proficiency in claims processing systems; Facets, Word, and Excel.
13. Excellent knowledge and understanding of Moda Health administrative policies affecting claims and customer service.
14. Demonstrates work habits that consistently exceeds Moda Health standards of attendance and punctuality as well as high flexibility.
15. Consistently communicates in a positive and effective manner, both written and verbal, to co-workers and management.
16. Receives and carries out tasks in a cooperative manner and demonstrates a spirit of teamwork.

Primary Functions:

1. Performs basic and moderately complex claim adjustments within the system while interpreting coding and understanding medical terminology in relation to diagnosis and procedures as well as member plan benefits.
2. Review, analyze, and resolve claims issues through the utilization of available resources for moderately complex claims.
3. Analyze and apply plan concepts to claims that include deductible, coinsurance, copay, COB, and out of pocket, etc.
4. Examines claims to determine if further investigation is needed from other departments and routes claims appropriately through the system.
5. Adjudication and adjustment of claims to achieve quality and production standards applicable to this position.
6. Release claims and adjustments by deadline to meet company, state regulations, contractual agreements, and group performance guarantee standards.
7. Reviews Policies and Procedures (P&Ps) for process instructions to ensure accurate and efficient claims processing as well as providing suggestions for potential process improvements.
8. Monitors and maintains unit inventory through adjustments, refunds, telephone calls and reports.
9. Prepares and sends refund requests and other form letters.
10. Reviews files, analyzes results, and organizes multiple adjustments and/or accumulator updates as needed.
11. Processes voided checks, reissues payment or manual checks, and works stop payments of checks. Issues follow up correspondence letters as needed.
12. Communicates via telephone with claimants, policyholders, providers, and other insurance carriers.
13. Thoroughly documents actions as required by internal procedure and market conduct guidelines.
14. Assists internal departments with programming issues as needed.
15. Responds and follows up using Facets, Content Manager and E-mail.
16. Provides back up to Medical Customer Service, COB and Medical Claims when requested.
17. Performs all job functions with a high degree of discretion and confidentiality in compliance with federal, state, and departmental confidentiality guidelines.
18. Perform other duties as assigned.

Working Conditions & Contact with Others:

• Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need.
• Internally with Claims, Customer Service, Healthcare Services, Membership Accounting, Information Technology, and Professional Relations. Externally with Providers, Members, Vendors, and Insurance companies. May serve on committees and appeals.

Together, we can be more. We can be better.

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 & Danielle Baker via our View email address on ziprecruiter.com email.