Medical Claims Support

ODS Companies Portland , OR 97228

Posted 2 months ago

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.

We are seeking a Medical Claims Support. This role is responsible for Assisting 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.

Primary Functions:

  • Communicates via telephone with claimants, policy holders, providers, and other insurance carriers.

  • Performs complex claim adjustments within the system while interpreting coding and understanding medical terminology in relation to diagnosis and procedures.

  • Review, analyze, and resolve claims issues through the utilization of available resources for complex claims.

  • Analyze and apply plan concepts to claims that include: deductible, coinsurance, copay, COB, and out of pocket, etc.

  • Examines claims to determine if further investigation is needed from other departments and routes claims appropriately through the system.

  • Ability to maintain balanced performance, which consistently exceeds expectations in areas of production and quality.

  • Release claims and adjustments by deadline to meet Company, state regulations, contractual agreements and group performance guarantee standards.

  • Reviews User Procedure Manuals (UPMs) for process instructions to ensure accurate and efficient claims processing as well as providing suggestions for potential process improvements.

  • Monitors and maintains unit inventory through adjustments, refunds, telephone calls and reports.

  • Prepares and sends refund requests, and other form letters.

  • Reviews Files and analyzes results and organizes multiple adjustments and/or accumulator updates as needed.

  • Processes voided checks, reissues payment or manual checks and stop payments of checks. Issues follow up correspondence letters as needed.

  • Thoroughly documents actions as required by internal procedure and market conduct guidelines.

  • Assists internal departments with correcting eligibility and programming issues as needed.

  • Responds and follows up using FACETS, Content Manager and E-mail.

  • Provides back up to Medical CS, COB and Medical Claims when requested

  • Performs all job functions with a high degree of discretion and confidentiality in compliance with federal, state and departmental confidentiality guidelines.

  • Assist with Lead responsibilities as necessary, review/release high dollar claims, answer questions for the team and update more complex accumulator issues.

  • Other duties as assigned.

Are you ready to be a betterist?

If you're ready to make a difference that matters, we want to hear from you. Because it's time to discover what's possible.

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.

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ODS Companies