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
Provides supervision, coaching and support to Claim Support staff.  Establishes goals, procedures and provide direction to ensure prompt and accurate support services.  Ensures department reports are prepared and quality assurance conducted. The ideal candidate resides near or within commuting distance of our Portland, Oregon office to support a hybrid work arrangement, however, remote status will be considered for out-of-area candidates. 

Pay Range
 $64,394.27 - $80,498.01 annually (depending on experience)
*This role may be classified as hourly (non-exempt) depending on the applicant's location. 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.

https://j.brt.mv/jb.do?reqGK=27770051&refresh=true

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. 10 years of claim experience including claim processing and/or customer service and/or claim support. 
3. Excellent oral and written communication skills and the ability to interact professionally, patiently, and courteously both in person and over the phone. 
4. Demonstrated strong, effective, diplomatic interpersonal skills with external clients as well as employees of all levels. 
5. Strong analytical, problem solving, and decision-making skills with demonstrated ability to handle and resolve complaints, correct errors and resolve departmental issues in accordance with Moda Health contracts and Moda Health Inc. policies. 
6. Strong knowledge of Microsoft Office products including Word and Excel. 
7. Strong reading, writing and verbal communication skills. 
8. Possess strong interpersonal skills necessary to deal with difficult issues and people. 
9. Possess analytical, problem solving and decision-making skills. 
10. Computer word processing and spreadsheet knowledge helpful. 
11. Must maintain confidentiality and project a professional business presence and appearance. 
12. Ability to come into work on time and daily. 
13. Must be able to work well under the pressure of supervising Sr. Level Processors and other class level staff responsible for a wide variety of key, non-routine functions requiring broad knowledge and excellent organizational and decision-making skills. 

Primary Functions:

1. Review and advise on the team’s response to provider inquiries, appeals, vendor pricing, and denials. Coordinate research for response with other departments. 
2. Ensure the timely and accurate response to written correspondence or phone calls on a wide variety of subjects including medical necessity for durable medical equipment appeals, subrogation, APC claims, vendor edits, and rental network pricing etc. 
3. Review and approve requests to change or revise benefit programming or contract wording resulting from claim processing problems. 
4. Log, track, and follow-up to ensure UPM revisions are completed. 
5. Oversee Quality Assurance Review and reporting.  Ensure consistency in Q/A procedures and reporting. 
6. Oversee clerical staff responsible for reject queue, fax/copier/printer maintenance, supplies, interoffice/interdepartmental mail. 
7. Oversee RxPricing claims and pharmacy code edit process. 
8. Review and determine equitable settlement on Third Party Liability/Subrogation claims. 
9. Responsible for Department Reporting. 
10. Responsible for ensuring prompt and accurate response to inquiries to Moda Health Website. 
11. Work closely with La Grande for Quality Assurance, complaints, appeals, and other claim support services. 
12. Ensure PPO pricing is performed promptly and accurately. 
13. Monitor Claim Support phone service and ensure adequate backup for Customer Service. 
14. Personnel administration including timekeeping, performance appraisals, interviewing and hiring, counseling, etc. 
15. Work with HealthCare Services and providers to obtain preauthorization. 
16. Perform other duties as assigned including membership in interdepartmental committees and projects. 

Working Conditions:

• 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 Customer Service, Claims, Healthcare Services, Sales/Service, Membership Accounting, Benefit Configuration, Actuarial, IT, and Provider Relations.  Externally with members, providers, policyholders, and vendors. 

Together, we can be more. We can be better.
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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 humanresources@modahealth.com email.