Hybrid Dental Claims Auditor I

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

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.