Dental Screen Auditor I (27788637)

Moda Partners, Inc.; Milwaukie (OR); Hybrid; USD 29,000 - 33,000; Full time

Benefits offered by this job

Medical, Dental, Pharmacy, Life & 

Disability

Job summary

Moda Health in Milwaukie, Oregon is seeking a full-time hybrid Claims Support Specialist to back up support leads, train staff, and handle complex claims adjustments and COB processing across Medicare, Oregon Health Plan, and commercial plans.

The role demands accuracy, strong communication, and comfort with data review, audits, and coordination with members and providers. Proficiency with 10-key, typing, and flexible hours including evenings/weekends is required.

Qualifications

• Understand and follow compliance rules to process claims.
• Document thoroughly as required by procedures.
• Interpret dental policies and contractual guidelines for claims.
• Communicate with members, providers, and other carriers by phone.
• Send custody, primary payment, refund request, and other form letters in a timely manner.
• Perform basic and complex adjustments using Facets, Content Manager, NEA Fast-Attach, emails, and reports.
• Interpret diagnostic X-rays and dental terminology to approve or refer claims for review.
• Investigate COB claims and update information.
• Review manuals and suggest process improvements.
• Identify trends and recommend efficiency improvements.
• Perform detailed file reviews for over/underpayments and support training units.
• Respond to Customer Service tasks/issues.
• Monitor logs for ASO prepay claims.
• Assist with data gathering for audits.
• Perform high-level review of clinical notes for relevancy.
• Perform other duties as assigned.

Responsibilities

• Understands and follows compliance rules to process claims including refunds and COB for Medicare, Oregon Health Plan, and commercial plans.
• Documents thoroughly as required by internal procedures and market conduct guidelines.
• Interprets requests from members, providers, and other departments to ensure compliance with guidelines.
• Communicates by telephone with members, providers, and other carriers.
• Sends custody, primary payment, refund requests, and other letters in a timely manner.
• Performs basic and complex adjustments on previously processed claims using listed tools.
• Interprets diagnostic x-rays and dental terminology to review clinical information and make approval decisions or refer for review.
• Investigates and processes COB claims promptly and updates information.
• Reviews User Procedure Manuals for process instructions and suggests improvements.
• Identifies trends and recommends process enhancements to increase efficiency and reduce errors.
• Performs detailed claims file reviews to determine over/underpayments and supports training units.

Skills

10-key proficiency

Typing speed

Communication

Attention to detail

Analytical thinking

Problem solving

Time management

Under pressure

Money tracking

Documentation

Student support/backup duties

Education

High school diploma or equivalent

Tools

Facets claims

CS tasks

Content Manager

NEA Fast-Attach

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

This is a FT hybrid position based in Milwaukie, Oregon. Provides backup to support leads including training of staff. Investigates complex file reviews and processes complex claims adjustments and Coordination of Benefits (COB) claims, including phone calls, overpayment recoveries, stop pays, and void checks. Responsible for sorting, assigning, and working various reports such as building member accumulators, giving deductible credits, adjusting claims to correct various provider updates.

Pay Range

$21.30 - $23.96 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.

Benefits

• Medical, Dental, Pharmacy, Life & Disability
• 401K - Matching
• FSA
• Employee Assistance Program
• PTO and paid holidays

Primary Functions

1. Understands and follows compliance rules to process claims including requesting refunds, and issuing additional benefits, for Medicare, Oregon Health Plan, commercial group, and individual plans.
2. Documents thoroughly as required by internal procedure and market conduct guidelines in a clear and concise manner and analyzes and interprets existing file notes and documentation.
3. Excellent knowledge and understanding of Delta Dental contractual and administrative policies affecting claims.Able to interpret requests from members, providers, and other internal departments to ensure the request is within contractual and administrative guidelines.
4. Communicates by telephone with members, providers, and other insurance carriers.
5. Sends custody, primary payment, refund request, and other form letters in timely manner.
6. Performs basic and complex adjustments on previously processed claims using Facets claims and CS tasks, Content Manager workbaskets, NEA Fast-Attach, emails, and reports.
7. In addition to basic and complex adjustments, uses ability to interpret diagnostic x-rays and dental terminology to review clinical information on claims to make approval decisions or send claim to dental consultants for further review.
8. Investigates and processes COB claims in a timely manner and updates information as required.
9. Reviews User Procedure Manuals (UPMs) for process instructions to ensure accurate and efficient claims processing as well as providing suggestions for potential process improvements.
10. Identify and refer trends in the system and procedures and recommend improvements to increase efficiency and reduce errors.
11. Performs detailed claims files review to determine over/underpayments and provides back up to claims processing and training units when needed.
12. Responds to and follows up with Customer Service tasks/issues.
13. Monitor logs with manually tracked offsets for ASO prepay claims.
14. Assist with gathering data as requested for group audits.
15. Ability to perform a high-level review of clinical chart notes for relevancy.
16. Performs other duties as assigned, including department reports and projects.

Position Proficiency Requirements

1. High school diploma or equivalent
2. 10-key proficiency of 105 kspm net on a computer numeric keypad.
3. Type a minimum of 25 wpm net on computer keyboard.
4. Strong reading, writing and verbal communication skills.
5. Ability to handle the most complex support functions accurately and timely.
6. Ability to back up on all Claim Support functions as well as accept additional responsibilities while still maintaining current workload.
7. Ability to work well under pressure with frequent interruptions and shifting priorities
8. Analytical, problem solving, organizational, and detail orientation skills.
9. Accurately track money received (refunds) and post to correct member, provider & group accounts.
10. Reviews Files and analyzes results and organizes multiple adjustments and/or accumulator updates as needed.
11. Accurately track and request appropriate funds to be reissued to members & providers.
12. Ability to maintain balanced performance, which meets expectations in areas of production and quality.
13. Meet or exceed company attendance standards.

Working Conditions & Contact with Others

• 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.
• Internally with various departments. Externally with provider offices, members, and other insurance carriers.

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 [e-mail] email.