Let’s do great things, together!

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.

This position provides backup to support leads including training of staff. Investigates complex file reviews and processes complex claims adjustments and Coordination of Benefits (COB) claims, including phone calls, overpayment recoveries, stop pays, and void checks. Responsible for sorting, assigning, and working various reports such as building member accumulators, giving deductible credits, adjusting claims to correct various provider updates.

This position is currently a full time Hybrid PST position for applicants living or willing to relocate to OR or WA.

Benefits:

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

• PST

Required Skills, Experience & Education:

• High school diploma or equivalent
• Strong reading, writing and verbal communication skills.
• Ability to handle the most complex support functions accurately and timely.
• Ability to back up on all Claim Support functions as well as accept additional responsibilities while still maintaining current workload.
• Ability to work well under pressure with frequent interruptions and shifting priorities
• Analytical, problem solving, organizational, and detail orientation skills.
• Accurately track money received (refunds) and post to correct member, provider & group accounts.
• Reviews Files and analyzes results and organizes multiple adjustments and/or accumulator updates as needed.
• Accurately track and request appropriate funds to be reissued to members & providers.
• Ability to maintain balanced performance, which meets expectations in areas of production and quality.
• Meet or exceed company attendance standards.

• Understands and follows compliance rules to process claims including requesting refunds, and issuing additional benefits, for Medicare, Oregon Health Plan, commercial group, and individual plans.
• Documents thoroughly as required by internal procedure and market conduct guidelines in a clear and concise manner and analyzes and interprets existing file notes and documentation.
• Excellent knowledge and understanding of Delta Dental contractual and administrative policies affecting claims. Able to interpret requests from members, providers, and other internal departments to ensure the request is within contractual and administrative guidelines.
• Communicates by telephone with members, providers, and other insurance carriers.
• Sends custody, primary payment, refund request, and other form letters in timely manner.
• Performs basic and complex adjustments on previously processed claims using Facets claims and CS tasks, Content Manager workbaskets, NEA Fast-Attach, emails, and reports.
• Investigates and processes COB claims in a timely manner and updates information as required.
• Reviews User Procedure Manuals (UPMs) for process instructions to ensure accurate and efficient claims processing as well as providing suggestions for potential process improvements.
• Identify and refer trends in the system and procedures and recommend improvements to increase efficiency and reduce errors.
• Performs detailed claims files review to determine over/underpayments and provides back up to claims processing and training units when needed.
• Responds to and follows up with Customer Service tasks/issues.
• Monitor logs with manually tracked offsets for ASO prepay claims.
• Assist with gathering data as requested for group audits.
• Ability to perform a high-level review of clinical chart notes for relevancy.
• Performs other duties as assigned, including department reports and projects.

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.

For more information regarding accommodations please direct your questions to Kristy Nehler and Daniel McGinnis via our humanresources@modahealth.com email.