Job Description

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 timely and accurate payment of Commercial and Medicaid inpatient hospital claims.  Answer internal questions from various departments and respond to correspondence from providers when necessary. This is a FT WFH role. 

Pay Range
$21.30 - $23.96 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.

Please fill out an application on our company page, linked below, to be considered for this position.

 

Benefits :

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

 

Required Skills, Experience & Education:

• High School diploma or equivalent.
• 1-2 years medical claims processing experience.
• 10-key proficiency of 135 wpm.
• Type a minimum of 35 wpm.
• Knowledge of medical terminology, CPT codes and ICD-10 codes.
• Strong verbal, written, and interpersonal communication skills.
• Analytical, problem solving and organizational skills.
• Ability to work well under pressure.
• Maintain confidentiality and project a professional business image
• Ability to maintain balanced performance in areas of production and quality.

Primary Functions :

• Review, process and adjust Commercial and Medicaid inpatient claims.
• Review claims data, interpreting coding and understanding medical terminology in relation to diagnosis and procedures.
• Review, analyze, price, and resolve inpatient claims through the utilization of available resources for moderate to complex inpatient claims, adjustments, and file reviews.
• Process Commercial and Medicaid inpatient claims for all types of contracts (e.g., DRG, per diem, case rate, % of CMS).
• Analyze and apply plan concepts to claims that include deductible, coinsurance, copay out of pocket, etc.
• Examine claims to determine if further investigation is needed from other departments and routes claims appropriately through the system.
• Contact providers and other outside sources for additional information.
• Adjudicate claims to achieve quality and production standards applicable to the position.
• Release claims by deadlines to meet company, state regulations, contractual agreements, and group performance guarantee standards.
• Review Policy and Procedures (P&P) for process instructions to ensure accurate and efficient claims processing as well as providing suggestions for potential process improvements.
• Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, state, and departmental confidentiality guidelines.
• Perform other duties as assigned.

Working Conditions & Contact with Others

• Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens. Work in excess of 37.5 hours per week, including evenings and occasional weekends, to meet business need.
• Works internally with Healthcare Services, Membership Accounting, Customer Service, Hospital Auditors, Provider Correspondence, and Professional Relations. Works externally with providers and vendors.  
   

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. 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 and Danielle Baker via our [email protected] email.

Job Tags

Hourly pay, Daily paid, Full time, Work at office, Work from home, Afternoon shift

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