Medical Claims Cob Processor

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.

Job Summary:
Investigates and processes COB (Coordination of Benefits) updates, COB claims, and COB related claim adjustments. Performs File Reviews, issues refund requests and completes all necessary steps needed for claims processing, updates, and adjustments. Assists in customer service inquiries regarding contractual and administrative policies and applies excellent customer service when a phone call is needed to complete a COB claim or adjustment.
Please fill out an application on our company page, linked below, to be considered for this position.

• https://j.brt.mv/jb.do?reqGK=27714766&refresh=true

Benefits:

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

Schedule:

• Full-time minimum 7.5 work days with 37.5 work weeks

Required Skills, Experience & Education:

1. High School diploma or equivalent.
2. Minimum of 6 months medical claim processing or customer service dealing with all types of plans/claims and consistently exceeding performance levels.
3. Professional and effective written and verbal communication skills.
4. 10-key proficiency of 135 spm net on a computer numeric keypad.
5. Type a minimum of 35 wpm net on a computer keyboard.
6. Ability to maintain balanced performance, which consistently exceeds minimum expectations in areas of production and quality.
7. Good analytical, problem solving, decision making and detail-oriented skills with ability to shift priorities as needed.
8. Good organizational abilities and the ability to handle a variety of functions .
9. Ability to multitask and work well under pressure and meet timelines.
10. Ability to maintain confidentiality internally and externally and project a professional business image always.
11. Proficiency in claims processing systems; Facets, Word, and Excel.
12. Knowledge and understanding of Moda Health administrative policies affecting claims and customer service.
13. Demonstrates work habits that include Moda Health standards of attendance and punctuality, as well as flexibility.

Primary Functions:

1. Communicates via telephone with claimants, policyholders, providers, and other insurance carriers.
2. Performs basic and moderately complex claim adjustments into the system while interpreting coding and understanding medical terminology in relation to diagnosis and procedures.
3. Review, analyze, and resolve claims through the utilization of available resources for complex claims.
4. Analyze and apply plan concepts to claims that include deductible, coinsurance, copay, COB, and out of pocket, etc.
5. Examines claims to determine if further investigation is needed from other departments and routes claims appropriately through the system.
6. Adjudication and adjustment of claims to achieve quality and production standards applicable to this position.
7. Release claims and adjustments by deadline to meet Company, state regulations, contractual agreements, and group performance guarantee standards.
8. Reviews User Procedure Manuals (UPMs) for process instructions to ensure accurate and efficient claims processing as well as providing suggestions for potential process improvements.
9. Monitors and maintains unit inventory through adjustments, refunds, telephone calls and reports.
10. Prepares and sends refund requests, and other form letters.
11. Reviews Files and analyzes results and organizes multiple adjustments as needed.
12. Thoroughly documents actions as required by internal procedure and market conduct guidelines.
13. Assists internal departments with correcting eligibility and programming issues as needed.
14. Responds and follows up using FACETS, Content Manager and E-mail.
15. Provides back up to Medical support and Medical Claims when requested.
16. Performs all job functions with a high degree of discretion and confidentiality in compliance with federal, state, and departmental confidentiality guidelines.
17. Perform other duties as assigned.

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.
For more information regarding accommodations please direct your questions to HRAdmin@modahealth.com.