Government Programs Appeal Coordinator I

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:
Investigate and respond to medical, pharmacy and dental grievances, complaints, appeals, and inquiries for the organization.  Respond to outside regulatory inquiries as needed. This position is in Government Programs.

This is a FT WFH position.

 

Pay Range

$21.30 - $23.96 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.

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

Benefits :

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

Primary Functions:

1. Research all grievances, complaints, correspondence, and appeals. Perform a complete review at each stage of the complaint/appeal process and ensure the appropriate documentation, including claim review to determine over/underpayment.
2. Respond in writing (or orally when appropriate) to requests, grievances, complaints, and appeals within the mandated timeframes.
3. Ability to maintain a full caseload.
4. Communicate effectively and appropriately with other departments to ensure complete and fair reviews of grievances, complaints, and appeals.
5. Communicate by letter and/or telephone with members, claimants, independent review entities, attorneys, and providers regarding claims/policies on Moda Health benefit plans.
6. Interpret contracts (evidence of coverage; handbooks) and determine actions required.
7. Respond to independent review entity requests for member case files within the stipulated timelines and ensure appropriate documentation required for reporting. Staff may also be required to respond to DFR requests or attend Medicaid hearings as a representative of the company.
8. Work with appropriate departments to effectuate decisions.
9. Meets the departments established production and accuracy standards for case completion.
10. Accurately document in system the outcome of grievances, complaints, and appeals.
11. Other duties as assigned

 

Required Skills & Experience:

1. High School diploma or equivalent.
   • 6 months to 2 years of experience of medical/dental claims processor or customer service preferred.
   • Demonstrated knowledge of CMS rules for Medicare and Medicaid grievance, complaint and appeal processes preferred.
   • Knowledge and understanding of complaint and appeal procedures preferred.
2. Ability to interpret benefit contracts and/or Moda Health administrative policies, products, and business lines.
3. Demonstrated strong reading, verbal, written and interpersonal communication skills.
4. Demonstrated initiative, analytical, problem solving, and organizational skills.
5. 10 key proficiency of 105 kspm on a numeric keypad.
6. Type a minimum of 25 wpm accurately on a computer keyboard.
7. Demonstrated proficiency in computer applications such as Word, Excel, or other core operating systems.
8. Ability to work well under pressure and meet deadlines while completing a high volume of work.
9. Ability to maintain confidentiality and project a professional business image.
10. Ability to adhere to Moda Health attendance policies and work assigned schedule which may include some overtime and occasional weekend and Holiday coverage.
11. Ability to communicate positively, patiently, and courteously.

 

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.

• Inside the company including with Medicare Programs, Medicaid Services, Professional Relations and Contracting, Customer Service, Membership Accounting, Claims, Legal Services, Regulatory, Compliance, Privacy and Healthcare Services teams. Outside the company with Members, Provider Offices, Independent Review Entities, Attorneys, and contracted vendors.

 

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 and Danielle Baker via our View email address on j.brt.mv email.