Medical Claims COB Processor I

Job Title

Medical Claims COB Processor I

Duration

Open until filled

Description

Let’s do great things, together!

About ModaFounded 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 SummaryInvestigates and processes Coordination of Benefits (COB) claims ensuring all necessary steps are completed for accurate claims processing. Handles customer service inquiries regarding contractual and administrative policies, providing excellent customer service when phone communication is required to resolve COB claims. This is a fully remote position.Pay Range$18.03 - $20.18 ​​​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.

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 diploma or equivalent.

• Minimum of 6 months medical claim processing or customer service dealing with all types of plans/claims and consistently exceeding performance levels.

• Professional and effective written and verbal communication skills.

• 10-key proficiency of 135 spm and a typing speed of 35 wpm on a computer keyboard.

• Ability to maintain balanced performance, which consistently exceeds minimum expectations in areas of production and quality.

• Strong analytical, problem-solving, and decision-making skills with ability to adapt to shifting priorities.

• Strong attention to detail and organizational skills, with the ability to manage multiple functions effectively.

• Ability to multitask and work well under pressure and meet timelines.

• Maintain confidentiality and project a professional business image.

• Proficiency in claims processing systems; Facets, Word, and Excel.

• Knowledge and understanding of Moda Health administrative policies affecting claims and customer service.

• Maintain Moda Health’s standards for attendance, punctuality, and flexibility.

Primary Functions:

• Communicate via telephone with claimants, policyholders, providers, and other insurance carriers.

• Review, analyze, and resolve complex claims utilizing available resources.

• Apply plan concepts such as deductibles, coinsurance, copay, COB, and out-of-pocket expenses to claims.

• Identify and route claims requiring further investigation within the system.

• Ensure timely claim releases to meet company policies, state regulations, contractual agreements, and group performance guarantees.

• Review Policies and Procedures (P&P) to ensure accurate claims processing and suggest process improvements.

• Monitor and maintain unit inventory.

• Thoroughly documents actions as required by internal procedure and market conduct guidelines.

• Assist internal departments with correcting eligibility and programming issues as needed.

• Respond to and follow up using FACETS, Content Manager and email.

• Provide back up to Medical Claims when requested.

• Maintain discretion and confidentiality in compliance with federal, state, and departmental guidelines.

• Work weekly itinerary reports.

• Consistently maintain high performance, exceeding expectations in production and quality.

• Handle various COB-related tasks, including:

• Copying Dual Moda claims

• Processing Vision COB claims

• Reviewing and submitting overpayment spreadsheets

• Completing updates

• Processing and adjusting Medicare and other claims.

• 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.

• Works internally with the customer service, membership accounting, and appeals departments. Works externally to support client needs.

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 via our humanresources@modahealth.com email.