Lets 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, were 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. Lets be better together.
Position Summary
Provides support to the Medical Management team by performing research on contracts, benefits, product changes and provider status. They are responsible to manage all lines of business. The Research Coordinator applies their understanding of a variety of complex business lines when responding to both internal and external communications. Pay Range
$22.88- $28.60 hourly (depending on experience)
Please fill out an application on our company page, linked below, to be considered for this position. Benefits : Medical, Dental, Vision, Pharmacy, Life, & Disability 401K- Matching FSA Employee Assistance Program PTO and Company Paid Holidays Required Skills, Experience & Education: High school education or equivalent. 2 - 4 years of experience in a medical environment and/or insurance experience required. Proficient in Microsoft Office applications. Type a minimum of 35 wpm and 10key proficiency of 135spm on computer number keypad. Excellent written, verbal, and interpersonal communication skills including demonstrated business writing and grammar skills. Excellent organizational and detail orientation skills. Must present a professional business image in all settings. Ability to work well under pressure, work with frequent interruptions and shifting priorities. Ability to come to work on time and daily. Ability to work independently, as well as part of a team, dealing with all levels of staff, members, providers, in a professional manner. Ability to maintain confidentiality. Basic knowledge of medical terminology. Primary Functions : Applies knowledge of various applications within the Facets claims payment system (e.g. customer service, benefits, eligibility, prospective Utilization Management) in order to manage incoming calls from providers related to requested service denials and the opportunity for peer to peer consultations with Plan physicians. Schedules and prepares documents for Peer to Peer appointments between external providers and Plan physicians; provides follow up case closure in Facets with the final determination outcome. Serves as a resource for Medical Management staff for inquiries that require Facets resolution due to changes in contracts, benefits, products, or provider status. Utilizes various applications (e.g. Facets, Careweb, CaseTrakker) to process and correct pended services due to contractual or product changes. Applies understanding of regulatory and accreditation standards related to the role. Handles appeal uphold and overturn decisions in the Facets claims payment system, maintaining timeliness and documentation standards. Performs scheduled internal Medical Management reporting needs including weekly case load acuity, MQIC reports and productivity reports. Manages external vendor invoices and reports for cases that fail to load automatically. Communicated member claims pay holds in Facets system related to alternative payment plans for cost effectiveness and single case agreements. Handles specialized account needs, and complex inpatient and outpatient account specific needs (e.g. customized benefit requests, overlapping coverage issues, special benefit handling). Identifies system and provider issues and trends; recommends changes to processes and takes lead in initiating improvements (e.g. team meeting discussions, creates job aides, initiation of procedure changes). Manages clinical text block sets for responses to provider service requests for prospective review team. Assists with tracking of department projects as requested by Manager Researches complex cases and prepares timelines as requested by Manager Triages Adverse Events, including requesting documents, sending to medical director review, notifying Peer Review committee, status updates, claim routing and communication with claims and medical management team. Assists with basic training of new medical management staff. Assists with implementation of new vendor services. Perform other duties as assigned. Working Conditions & Contact with Others 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. Internally with multiple departments. Externally with provider offices, hospitals, members, home health agencies, and pharmacies.
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 Daniel McGinnis via our email.
