About the Role
Moda Health is seeking a dedicated and empathetic Health Navigator I to join our mission of building a healthier future together. In this critical, member-facing role, you will act as a primary point of contact for our Moda 360 and Performance Guarantee groups, delivering exceptional service across phone, email, and digital chat platforms. You will go beyond traditional customer service by becoming a true health advocate—analyzing complex inquiries, researching coverage solutions, and guiding our members toward the best possible health outcomes with professionalism and care.
As a Health Navigator, you will thrive in a fast-paced, remote environment that rewards initiative and continuous learning. Whether you are assisting a member with a complex pharmacy claim, helping a patient find an in-network provider, or explaining intricate dental benefits, your goal is to reduce member effort and provide total resolution. This position offers a clear career path, with opportunities for advancement to Health Navigator II as you master multiple lines of business and deepen your expertise in the healthcare landscape.
Key Responsibilities- Serve as a primary advocate for members by answering inquiries regarding medical, dental, and pharmacy benefits, claims, and authorizations.
- Utilize the Moda 360 Navigator Console to review personalized member data and recommend specific health actions or clinical programs.
- Conduct thorough research by navigating multiple systems simultaneously, including Facets, Benefit Tracker, and pharmacy portals, to resolve issues completely.
- Communicate effectively with providers, pharmacies, and internal departments to facilitate care and resolve billing or coverage discrepancies.
- Handle high-volume interactions via phone, online chat, SMS, and email while maintaining a professional and composed demeanor under pressure.
- Apply critical thinking and mathematical skills to calculate benefit incentives and verify the accuracy of processed claims.
- Document all interactions with precision and detail, ensuring a seamless experience for the member during future contacts.
- Identify and report system configuration errors or confusing plan documentation to leadership to improve the overall member experience.
- Support members through the complaints and grievances process by providing clear, transparent explanations of plan policies.
- High school diploma or equivalent certification required.
- Proven experience in customer service, medical/dental office administration, pharmacy support, or insurance claim processing.
- Strong proficiency in Microsoft Office Suite, specifically Outlook, OneNote, and Microsoft Teams.
- Exceptional communication skills, with the ability to explain complex technical information in easy-to-understand language.
- Technical aptitude to manage multiple monitors and toggle between several complex software applications (such as TriZetto Facets) simultaneously.
- Minimum typing speed of 25 WPM and 10-key proficiency of 105 KPM net.
- Ability to maintain a flexible work schedule and demonstrate excellent punctuality in a remote work setting.
- Knowledge of medical, dental, or pharmacy terminology and CPT/ICD-10 coding is highly preferred.
- Ability to complete the 'Effortless Experience' certification training upon hire.
- Comprehensive Medical, Dental, Vision, and Pharmacy coverage.
- 401(k) retirement plan with employer matching contributions.
- Generous Paid Time Off (PTO) and company-paid holidays.
- Flexible Spending Accounts (FSA) for healthcare and dependent care.
- Life and Disability insurance for long-term financial security.
- Employee Assistance Program (EAP) providing mental health and wellness support.
- Dedicated career development pathways and internal promotion opportunities.