Medical Claims Processor 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.

Position Summary

Responsible for utilizing resources efficiently for the accurate and timely entry, review, and resolution of simple to moderately complex medical claims in accordance with policies, procedures, and guidelines as outlined by the company. This is a FT WFH role.

Pay Range

$17.34 - $19.41 hourly, DOE.

• 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.
  
  

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

• High School diploma or equivalent
• 6-12 months data entry or medical office experience preferred
• 10-key proficiency of 135 spm
• Type a minimum of 35 wpm
• Knowledge of medical terminology, CPT codes and ICD-9/10 codes preferred
• Demonstrates work habits that include punctuality, organization, and flexibility
• Ability to maintain balanced performance in areas of production and quality
• Analytical reasoning and flexibility
• Professional and effective written and verbal communication skills
• Experience with Facets platform a plus
• Identify all the duties and responsibilities
  
  

• Enters claims data into system while interpreting coding and understanding medical terminology in relation to diagnosis and procedures.
• Review, analyze, and resolve claims through the utilization of available resources for moderately complex claims.
• Analyze and apply plan concepts to claims that include deductible, coinsurance, copay, out of pocket, etc.
• Examines claims to determine if further investigation is needed from other departments and routes claims appropriately through the system.
• Adjudication of claims to achieve quality and production standards applicable to this position.
• Release claims by deadline to meet company, state regulations, contractual agreements, and group performance guarantee standards.
• Reviews Policies and Procedures (P&P’S) for process instructions to ensure accurate and efficient claims processing as well as providing suggestions for potential process improvements.
• Performs all job functions with a high degree of discretion and confidentiality in compliance with federal, state, and departmental confidentiality guidelines.
• Flexible schedule that may include working 5 hours of overtime on pre-determined Saturdays to meet business needs. Moda’s standard workweek is a 37.5 hour work week.
  
  

• Office environment with extensive close PC and keyboard work with constant sitting. Must be able to navigate multiple screens. Flexible schedule that may include working 5 hours of overtime on pre-determined Saturdays to meet business needs. Moda’s standard workweek is a 37.5 hour work week.
• Works internally with the customer service, membership accounting, and appeals departments. Works externally to support client needs.
  
  

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