Medical Claims Support I

Medical Claims Support I - Remote

Moda Health is seeking a dedicated and detail-oriented Medical Claims Support I to join our team. This is a full-time, permanent, remote position.

Founded in Oregon in 1955, Moda Health is committed to building a better future for healthcare by offering outstanding coverage to our members, compassionate support to our community, and comprehensive benefits to our employees. We value diversity and inclusion in our workplace and invite applications from candidates who share this commitment.

About the Role

As a Medical Claims Support I, you will investigate and process claim adjustments for all medical lines of business and COB (coordination of benefits) claim adjustments for Medicare/Medicaid plans. You will also handle adjustments related to overpayment recovery, underpayment adjustments, and other corrections. This role involves performing COB updates, file reviews, issuing adjustment-related letters to members and providers, processing payment offsets, and validating stop payment requests. You will also assist with customer service inquiries regarding contractual and administrative policies, applying excellent customer service when phone support is needed to complete adjustments or other tasks.

Key Responsibilities

• Investigate and process claim adjustments for all medical lines of business and COB claim adjustments for Medicare/Medicaid plans.
• Process adjustments related to overpayment recovery, underpayment adjustments, and other corrections.
• Perform COB updates (excluding Commercial), file reviews, and issue adjustment-related letters to members and providers.
• Perform payment offsets and validate/complete stop payment requests.
• Assist with customer service inquiries regarding contractual and administrative policies.
• Interpret coding and understand medical terminology in relation to diagnosis and procedures, as well as member plan benefits.
• Analyze and resolve claims issues using available resources.
• Apply plan concepts to claims, including deductible, coinsurance, copay, COB, and out-of-pocket expenses.
• Examine claims to determine if further investigation is needed from other departments and route them appropriately.
• Adjudicate and adjust claims to meet quality and production standards.
• Release claims and adjustments by deadlines to meet company, state regulations, contractual agreements, and group performance guarantee standards.
• Review Policies and Procedures (P&Ps) for process instructions and suggest potential improvements.
• Monitor and maintain unit inventory through adjustments, refunds, telephone calls, and reports.
• Prepare and send refund requests and other form letters.
• Process voided checks, reissues, manual checks, and work stop payments.
• Communicate via telephone with claimants, policyholders, providers, and other insurance carriers.
• Document actions thoroughly as required by internal procedure and market conduct guidelines.
• Provide backup to Medical Customer Service, COB, and Medical Claims when requested.
• Maintain a high degree of discretion and confidentiality in compliance with federal, state, and departmental guidelines.

Requirements

• High School diploma or equivalent.
• Minimum of 6 months of medical claim processing or customer service experience dealing with all types of plans/claims, consistently exceeding performance levels.
• Professional and effective written and verbal communication skills.
• 10-key proficiency of 135 words per minute net on a computer numeric keypad.
• Typing speed of a minimum of 35 words per minute net on a computer keyboard.
• Demonstrated ability to maintain balanced performance, consistently exceeding expectations in production and quality.
• Strong and proficient organizational abilities and the capacity to handle a variety of functions.
• Ability to efficiently multitask, 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 the ability to shift priorities as needed.
• Strong proficiency in claims processing systems, including Facets, Microsoft Word, and Microsoft Excel.
• Excellent knowledge and understanding of Moda Health administrative policies affecting claims and customer service.
• Demonstrates work habits that consistently exceed Moda Health standards of attendance, punctuality, and flexibility.
• Consistently communicates in a positive and effective manner, both written and verbal, to co-workers and management.
• Receives and carries out tasks in a cooperative manner and demonstrates a spirit of teamwork.
• Must have a reliable, high-speed, hard-wired internet connection to support remote work.
• Must be comfortable being on camera for virtual training and meetings.

What We Offer

• Medical, Dental, Vision, Pharmacy, Life, & Disability insurance.
• 401K with matching contributions.
• Flexible Spending Account (FSA).
• Employee Assistance Program.
• Paid Time Off (PTO) and Company Paid Holidays.

Moda Health is an equal opportunity employer. All qualified applicants will