Medical CS Rep I ()

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.

About the role

Provides phone customer service to members of multiple benefit plans by analyzing caller’s needs and providing timely and accurate responses. Answers calls from policyholders, members, agents, providers, hospitals, pharmacists and others regarding a wide variety of issues and questions related to a member's health plan. These can include explaining benefits, claims processing and other details of the plan. This is a full-time work-from-home position.

Responsibilities

• Answers 50+ calls a day regarding claims and benefit questions from callers on both group and individual plans.
• Provide solutions to problems, confirm eligibility, verify premiums and collect payments for members on individual plans, explain benefits and/or plan coverage.
• Ability to repeatedly analyze situations, communicate effectively in a fast-paced environment that includes dealing with frustrated or angry callers.
• Provide accurate information in a professional manner.
• Apply mathematical skills to determine correct benefit information and premium amounts for Individual plans.
• Exercise judgement, initiative, and discretion in confidential and sensitive manners.
• Review, update and become familiar with new and revised benefit information or claim processing procedures.
• Review and explain any authorization requirements of the plan using online tools available.
• Update and enter primary care physician selections if required by member’s plan.
• Gather banking details so monthly premium for members on Individual plans can be collected.
• Request claim adjustments required because of error in processing or any new information that has been received.
• Resolve and record complaints, appeals, and inquiries.
• Complete provider searches using available online web-based systems to assist members in finding providers that meet their needs and that of the plan.
• Contact physicians, dentists, hospitals, and other providers when necessary to answer questions and obtain or provide information.
• Provide timely follow-up and return calls when required.
• Document all aspects of a call in a clear and concise manner.
• Answer calls within service level time.
• Other duties and projects as assigned by Manager/Supervisor/Lead.

Requirements

• High school diploma or equivalent.
• Practical knowledge of medical terminology desired.
• Knowledge of diagnosis and procedure coding desired.
• Claim processing experience or prior customer service experience or other related experience such as medical/dental office experience.
• Excellent oral and written communication skills.
• Ability to interact professionally, patiently, and courteously with customers over the phone.
• Good analytical, problem-solving and decision-making skills.
• 10-key proficiency of 105 spm net on a computer numeric keypad.
• Type a minimum of 25 wpm net on a computer keyboard.
• High-speed internet (cable or fiber).
• Must be proficient with Microsoft Office applications with the ability to open and navigate multiple windows at the same time.
• Ability to achieve and maintain quality and quantity standards.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Ability to be at work on time and daily.
• Maintain confidentiality and project a professional business presence.
• Ability to organize and remain up to date on changing and new information.

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.

Contact with others includes internally with Medical Claims, Healthcare Services, Marketing, Membership Accounting, Provider Relations, Pharmacy and Case Management, and externally with members, providers, attorneys, policyholders, brokers, government officials, and other insurance carriers.

Pay

$18.39 - $20.58 hourly (depending on experience). 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.

Benefits

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