Medical Claims COB Processor I (27786190)

Moda Partners, Inc.; Oregon; On-site; USD 25,000 - 28,000; Full time

Benefits offered by this job

Medical, Dental, Vision, Pharmacy,Life

401K- Matching

FSA

Employee Assistance Program

PTO and Company Paid Holidays

Job summary

Moda Health in Oregon seeks a COB Claims Processor to investigate and process Coordination of Benefits (COB) claims and respond to customer inquiries with excellent service.

This full-time work-from-home position requires attention to detail, accuracy, and proficiency with Facets, Microsoft Word and Excel. Eligible employees receive comprehensive benefits, PTO, and a competitive 401(k) plan.

Qualifications

• High School diploma or equivalent.
• Minimum of 6 months medical claim processing or customer service experience.
• Professional and effective written and verbal communication skills.
• 10-key proficiency of 135 spm on a computer numeric keypad.
• Type a minimum of 35 wpm net on a computer keyboard.
• Maintain balanced performance in production and quality.
• Good analytical, problem solving, decision making and detail-oriented skills.
• Proficiency in claims processing systems; Facets, Word, and Excel.
• Knowledge of Moda Health administrative policies affecting claims and customer service.
• Demonstrates attendance, punctuality, and flexibility.

Responsibilities

• Communicates via telephone with claimants, policyholders, providers, and other insurance carriers.
• Review, analyze, and resolve claims using available resources for complex cases.
• Apply plan concepts to claims including deductible, coinsurance, copay, COB, and out-of-pocket.
• Route claims for further investigation within the system as needed.
• Release claims by deadline to meet regulations and group standards.
• Maintain confidentiality in line with guidelines.
• Document actions per internal procedures and market conduct guidelines.
• Assist internal departments with eligibility and programming issues as needed.
• Respond and follow up using FACETS, Content Manager and E-mail.
• Provide backup to Medical Claims when requested.

Skills

Medical claim processing

Customer service

Communication

10-key proficiency

Typing 35 wpm

Attention to detail

Analytical skills

Confidentiality

Multitasking

Adaptability

Education

High School diploma or equivalent

Tools

Facets

Word

Excel

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

Investigates and processes COB (Coordination of Benefits) COB claims, and completes all necessary steps needed for claims processing. 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.

This is a FT WFH role

Pay Range

$18.39 - $20.58 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, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

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. Review, analyze, and resolve claims through the utilization of available resources for complex claims.
3. Analyze and apply plan concepts to claims that include deductible, coinsurance, copay, COB, and out of pocket, etc.
4. Examines claims to determine if further investigation is needed from other departments and routes claims appropriately through the system.
5. Release claims by deadline to meet Company, state regulations, contractual agreements, and group performance guarantee standards.
6. Maintain discretion and confidentiality in compliance with federal, state, and departmental guidelines.
7. Reviews Policy and Procedures (P&P) for process instructions to ensure accurate and efficient claims processing as well as providing suggestions for potential process improvements.
8. Monitors and maintains unit inventory.
9. Thoroughly documents actions as required by internal procedure and market conduct guidelines.
10. Assists internal departments with correcting eligibility and programming issues as needed.
11. Responds and follows up using FACETS, Content Manager and E-mail.
12. Provides back up to Medical Claims when requested.
13. Performs all job functions with a high degree of discretion and confidentiality in compliance with federal, state, and departmental confidentiality guidelines.
14. Perform other duties as assigned.
15. Work weekly Itinerary reports
16. Ability to maintain balanced performance, which consistently exceeds expectations in areas of production and quality.
17. Work on other new COB related functions as needed.Copy Dual Moda claims
18. Work Vision COB claims
19. Review and submit Overpayment spreadsheet
20. Complete updates
21. Process Medicare COB claims
22. Adjust COB claims
23. Work Clinical Edit (CE) COB claims as needed
24. Identify and route claims requiring further investigation within the system.

Working Conditions & Contact with Others

• Works internally with the customer service, membership accounting, and appeals departments. Works externally to support client needs. Must be able to navigate multiple screens. Be able to work extra hours during the work week and occasional Saturdays to meet business needs.
• 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.

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 & Danielle Baker via our [e-mail] email.