View on Remote OK
Roles
Compensation
USD 21 - 23
Pay range $21.30 - $23.96 hourly; actual pay based on qualifications. Benefits include Medical, Dental, Vision, Pharmacy, Life, Disability, 401(k) matching, FSA, Employee Assistance Program, PTO and Company Paid Holidays.
- Salary period
- hourly
- Location basis
- Portland (remote role); pay range stated as hourly.
Benefits
- Medical
- Dental
- Vision
- Pharmacy
- Life
- Disability
- 401(k) matching
- FSA
- Employee Assistance Program
- PTO and Company Paid Holidays
Tech stack
Required
Nice to have
Location
Portland
Work setup
- Employment
- full-time
- Level
- Mid-level
- Remote policy
- Remote OK; Work arrangement: Remote; This is FT WFH role.
- Remote scope
- unclear
Role details
Responsibilities
- Provides phone, email and chat-based customer service to members by analyzing needs and providing timely and accurate responses.
- Answers inquiries from policyholders, members, agents, providers, hospitals, pharmacists, dentists and others regarding issues and questions related to member benefits and health program options.
- Handle medical, dental and/or pharmacy claim, authorization and benefit questions from customers on specific groups.
- Provide solutions to problems, confirm eligibility and explain benefits and plan coverage.
- Handle inquiries received via phone, email, voicemail and/or online chat.
- Respond to members via phone, online chat, SMS and email; complete detailed research and follow-up as needed.
- Use multiple resources simultaneously to research member issues and resolve situations with internal departments and multiple phone calls to providers, pharmacies and other carriers.
- Work with internal departments via email, phone or meetings to resolve member issues and ensure clear communication of member needs.
- Analyze situations and communicate effectively in a fast-paced environment, including with frustrated or angry callers.
- Use the Moda 360 Navigator Console to review recommended health actions and programs, recommend programs based on personalized member data, and assist members with setup or completion of recommended actions/programs.
- Document interactions while talking on the phone or responding via chat.
- Apply mathematical skills to determine correct benefit and claim information and manually calculate and update dental incentive levels when needed.
- Exercise judgment and discretion with confidential and sensitive subject matter.
- Provide thorough resolution for members using critical thinking; reach out to internal/external sources and make multiple follow-up calls until resolved.
- Review, update, and become familiar with new and revised benefit information.
- Build and maintain proficiency in claim processing procedures to determine whether a claim was processed or adjusted correctly.
- Communicate reasoning to callers in language appropriate to the caller’s experience level.
- Request claim adjustments required due to processing or configuration errors or new information; determine configuration vs processing errors; communicate with leadership to correct configuration errors.
- Identify confusing or incomplete information in internal/external resources, plan documents and member communications and suggest improvements.
- Update and enter primary care physician selections based on plan benefits (medical only).
- Complete provider searches, including calling providers to locate in-network, available providers meeting member care needs.
- Work with internal departments to help resolve member gaps in care, including exceptions and authorizations for those trained in medical or pharmacy.
- Advocate on behalf of members when encountering issues obtaining covered care or medications.
- Place pharmacy overrides to allow pharmacies to dispense medication at point of service when appropriate (pharmacy only).
- Address and explain complaints, appeals, and grievances.
- Provide customer service to walk-in members.
- Send emails or text messages to members to follow up on call details or provide forms/links/plan documents.
- Send faxes to providers to allow submission of medication authorization requests (pharmacy only).
- Provide timely follow up and return calls when required.
- Answer calls within PG service level agreement.
- Complete continuing education on customer service skills.
- Perform other related duties and projects as assigned by lead, supervisor or manager.
Requirements
- High school diploma or equivalent.
- Ability to complete training as a Customer Service Representative with Moda Health.
- Claim processing experience, prior customer service experience or other related experience such as medical/dental office or pharmacy preferred.
- Practical knowledge of medical, dental and/or pharmacy terminology desired.
- Knowledge of diagnosis and procedure coding helpful.
- Excellent oral and written communication skills; ability to interact professionally, patiently, and courteously with customers over the phone and in writing.
- Excellent analytical, problem solving and decision-making skills.
- 10-key proficiency of 105 kpm net on a computer numeric keypad.
- Type a minimum of 25 wpm net on computer keyboard.
- Ability to work well under pressure in a complex and rapidly changing environment.
- Ability to maintain excellent attendance and punctuality.
- Maintain confidentiality and project a professional business presence.
- Ability to work with multiple applications across multiple monitors at once and learn new applications as needed.
- Experience using Microsoft Office products including Outlook, OneNote and Teams.
- Experience with TriZetto Facets helpful.
- Ability to learn independently and take initiative to constantly improve skills.
- Internal candidates must be Fully Meeting performance expectations in their current position; exceeding in accuracy and customer service skills is preferred.
- Complete Effortless Experience training and certification after hire.
Application
Please fill out an application on our company page, linked below, to be considered for this position.
- Portfolio
- not required
- GitHub
- not required
- Cover letter
- not required
- Apply flow
- external
Company context
Building a better future for healthcare by offering outstanding coverage to members, compassionate support to the community, and comprehensive benefits to employees.
- Product
- Health insurance and healthcare benefits programs (Moda Health members, Moda 360 groups, Performance Guarantee groups).
- Industry
- Healthcare
- HQ
- Oregon
Contact
Kristy Nehler, Danielle Baker
humanresources@modahealth.com
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. Job Summary Provides phone, email and chat-based customer service to members of certain Performance Guarantee (PG) and Moda 360 groups by analyzing caller’s needs and providing timely and accurate responses. Answers inquiries from policyholders, members, agents, providers, hospitals, pharmacists, dentists and others regarding a wide variety of issues and questions related to a member’s benefits and health program options. This position requires staff to be flexible with their work schedule to meet the client’s needs. This is FT WFH role. Primary Functions Applicants will handle either medical, dental or pharmacy inquiries or a combination of two of these, depending on existing skills and training. Opportunity for promotion to Health Navigator II upon learning all three lines of business. Answer medical, dental and/or pharmacy claim, authorization and benefit questions from customers on specific groups. Provide solutions to problems, confirm eligibility and explain benefits and plan coverage. Handle inquiries received via phone, email, voicemail and/or online chat. Respond to members via phone, online chat, SMS and email. Complete detailed research and follow-up as needed. May include use of multiple resources, contact with internal departments and multiple phone calls to providers, pharmacies and other carriers to resolve a situation completely. Work with internal departments via email, phone or meetings to resolve member issues and ensure clear communication of the member’s needs. Repeatedly analyze situations and communicate effectively in a fast-paced environment that includes working with frustrated or angry callers. Use the Moda 360 Navigator Console to review recommended health actions and programs, recommend programs based on personalized member data and assist members in understanding and setting up programs or completing recommended health actions. Use multiple resources simultaneously to research member issues. These could include Facets, Benefit Tracker, Content Manager, eviCore portal, Navitus, CoverMyMeds, Moda 360 Navigator Console and other internal and external websites depending on the line(s) of business. Provide complete and accurate information in a professional manner both verbally and in writing. Talk on the phone or respond via chat while simultaneously researching the caller’s questions and documenting the interaction. Exercise judgment, initiative, and discretion with confidential and sensitive subject matter. Provide thorough resolution when at all possible for members by using critical thinking skills, extending yourself and reducing effort on the part of the caller. This could include reaching out to internal and external sources (including service providers) to assist in resolving the issue for the member and making multiple follow-up calls to the member until the issue is resolved. Perform related duties: review, update and become familiar with new and revised benefit information; build and maintain proficiency in claim processing procedures; communicate reasoning to callers; request claim adjustments; communicate with leadership when configuration errors are encountered; identify confusing or incomplete information and suggest improvements. Update and enter primary care physician selections based on plan benefits (medical only). Complete provider searches (including calling providers to locate in-network, available providers). Work with internal departments on gaps in care, including exceptions and authorizations for trained medical or pharmacy. Advocate for members when obtaining covered care or medications. Place overrides to allow pharmacies to dispense at the point of service when appropriate (pharmacy only). Address and explain complaints, appeals, and grievances. Provide customer service to walk-in members. Send emails or text messages to members to follow up on call details or provide forms, website links or other plan documents. Send faxes to providers to allow them to submit medication authorization requests (pharmacy only). Provide timely follow up and return calls when required. Answer calls within PG service level agreement. Complete continuing education on customer service skills. Contact With Others & Working Conditions Constant sitting and telephone use; close PC monitor and keyboard work. Must work with multiple applications open on multiple monitors. Constant interaction with others on the phone, in writing and in person. Video calls via MS Teams when required by supervisor or manager. Inside the company with Medical Claims, Healthcare Services, Dental Claims, Dental Provider Relations, Marketing, Group Integration, Medical Provider Relations, Pharmacy Operations, Case Management and others. Outside the company with members, providers, attorneys, policyholders, brokers, service providers, pharmacies and other insurance carriers. Equal Employment Opportunity statement and accommodations contact information provided. Application instruction includes mentioning the word DECISIVE and tagging RMTM4LjIwMS4xMjYuMTgx when applying.
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