View on Remote OK
Roles
Compensation
USD 21 - 23
Pay range $21.30 - $23.96 hourly (DOE). Actual pay based on qualifications. Benefits include Medical, Dental, Vision, Pharmacy, Life & Disability; 401K matching; FSA; Employee Assistance Program; PTO and Company Paid Holidays.
- Salary period
- hourly
Benefits
- Medical
- Dental
- Vision
- Pharmacy
- Life & Disability
- 401K matching
- FSA
- Employee Assistance Program
- PTO
- Company Paid Holidays
Tech stack
Required
Location
Portland,
Work setup
- Employment
- full-time
- Level
- Mid-level
- Remote policy
- Remote OK; Work arrangement: Remote. Reliable, high-speed, hard-wired internet connection required to support remote or hybrid work; comfortable being on camera for virtual training and meetings.
- Remote scope
- country-limited
Role details
Responsibilities
- Investigate and process claim adjustments for all medical lines of business
- Process COB claim adjustments for Medicare/Medicaid plans
- Process adjustments related to overpayment recovery, underpayment adjustments, and other corrections
- Perform COB updates (excluding Commercial)
- Review files and issue adjustment-related letters to members and providers
- Perform payment offsets and validate and complete stop payment requests
- Assist with customer service inquiries regarding contractual and administrative policies
- Complete claim adjustments within the system while interpreting coding and understanding medical terminology in relation to diagnosis and procedures and member plan benefits
- Review, analyze, and resolve claims issues using available resources
- Analyze and apply plan concepts to claims including deductible, coinsurance, copay, COB, and out of pocket
- Examine claims to determine if further investigation is needed and route claims appropriately through the system
- Release claims and adjustments by deadline to meet company/state regulations and contractual/group performance standards
- Review policies and procedures (P&Ps) for process instructions; suggest process improvements
- Monitor and maintain unit inventory through adjustments, refunds, telephone calls, and reports
- Prepare and send refund requests and other form letters
- Review files, analyze results, and organize multiple adjustments and/or accumulator updates as needed
- Process voided checks, reissues payment or manual checks, and work stop payments of checks
- Issue follow-up correspondence letters as needed
- Communicate via telephone with claimants, policyholders, providers, and other insurance carriers
- Thoroughly document actions as required by internal procedure and market conduct guidelines
- Assist internal departments with programming issues as needed
- Respond and follow up using Facets, Content Manager, and E-mail
- Provide backup to Medical Customer Service, COB and Medical Claims when requested
- Perform all job functions with discretion and confidentiality in compliance with federal, state, and departmental confidentiality guidelines
Requirements
- High school diploma or equivalent
- Minimum of 6 months medical claim processing or customer service dealing with all types of plans/claims and consistently exceeding performance levels
- At least 12 months experience as a Processor I and consistently performing at an exceeding level of performance (or Support Processor I designation obtained through equivalent work experience and knowledge level at Moda Health or recruiting externally)
- Professional and effective written and verbal communication skills
- 10-key proficiency of 135 wpm net on a computer numeric keypad
- Type a minimum of 35 wpm net on a computer keyboard
- Ability to maintain balanced performance consistently exceeding expectations in production and quality
- Strong and proficient organizational abilities; ability to handle a variety of functions
- Ability to efficiently multitask and work well under pressure and meet timelines
- Ability to maintain confidentiality internally and externally and project a professional business image
- Strong analytical, problem solving, decision making, and detail-oriented skills with ability to shift priorities as needed
- Strong proficiency in claims processing systems: Facets, Word, and Excel
- Excellent knowledge and understanding of Moda Health administrative policies affecting claims and customer service
- Work habits that consistently exceed Moda Health standards of attendance and punctuality and high flexibility
- Consistently communicates positively and effectively with co-workers and management
- Receives and carries out tasks cooperatively and demonstrates a spirit of teamwork
Application
Please fill out an application on our company page, linked below, to be considered for this position. Please mention the word OUTSTANDINGLY and tag RODguMTk4Ljk5LjE0Mw== when applying to show you read the job post completely (#RODguMTk4Ljk5LjE0Mw==).
- Portfolio
- not required
- GitHub
- not required
- Cover letter
- unclear
- Apply flow
- ats
Company context
Building a better future for healthcare; offering outstanding coverage to members and compassionate support to the community.
- Product
- Healthcare coverage and claims processing
- Industry
- Healthcare
- HQ
- Oregon
Contact
Kristy Nehler, Danielle Baker
humanresources@modahealth.com
Description
Investigates and processes claim adjustments for all medical lines of business and COB claim adjustments for Medicare/Medicaid plans. 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 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. FT WFH role. 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.
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