Medical Claims Support I

The role involves processing and investigating medical claim adjustments, handling COB updates, and providing customer service support related to claims for Moda Health. It is a full-time work-from-home position focused on claims processing and customer support within the healthcare insurance sector.

Location: Remote (US)

Salary: $21.30 - $23.96 hourly, DOE

Responsibilities

• Performs claim adjustments within the system, interpreting coding and medical terminology.
• Reviews, analyzes, and resolves claims issues using available resources.
• Analyzes and applies plan concepts such as deductible, coinsurance, copay, COB, and out-of-pocket.
• Examines claims for further investigation needs and routes claims appropriately.
• Adjudicates and adjusts claims to meet quality and production standards.
• Releases claims and adjustments by deadlines to comply with regulations and contractual standards.
• Reviews policies and procedures for process improvements.
• Monitors and maintains unit inventory through adjustments, refunds, and reports.
• Prepares and sends refund requests and correspondence.
• Analyzes files, organizes adjustments, and updates accumulators.
• Processes voided checks, reissues payments, and manages stop payments.
• Communicates with claimants, policyholders, providers, and other carriers via phone.
• Documents actions thoroughly according to procedures.
• Assists internal departments with programming issues.
• Responds and follows up using Facets, Content Manager, and email.
• Provides backup support to Medical Customer Service, COB, and Medical Claims.
• Maintains confidentiality and complies with legal guidelines.
• Performs other duties as assigned.

Requirements

• High School diploma or equivalent.
• Minimum of 6 months medical claim processing or customer service experience with all types of plans/claims.
• At least 12 months experience as a Processor I, exceeding performance levels.
• Effective written and verbal communication skills.
• 10-key proficiency of 135 wpm net.
• Typing speed of at least 35 wpm net.
• Consistent pattern of exceeding performance expectations in production and quality.
• Strong organizational skills and ability to handle multiple functions.
• Ability to multitask, work under pressure, and meet deadlines.
• Maintain confidentiality and project professionalism.
• Strong analytical, problem-solving, decision-making, and detail-oriented skills.
• Proficiency in claims processing systems (Facets), Word, and Excel.
• Knowledge of Moda Health policies affecting claims and customer service.
• Excellent attendance, punctuality, and flexibility.
• Positive communication skills and teamwork orientation.

Benefits

• Medical, Dental, Vision, Pharmacy, Life, & Disability insurance.
• 401K with matching.
• FSA (Flexible Spending Account).
• Employee Assistance Program.
• Paid Time Off (PTO) and company-paid holidays.

Additional Information

• This is a full-time work-from-home role.
• Work involves extensive computer use, constant sitting, and frequent phone communication.
• Must have reliable high-speed internet and be comfortable on camera for virtual meetings.
• Work may include evenings and weekends to meet business needs.
• Work with internal departments and external providers, members, vendors, and insurance companies.