Medical Claims Processor I

About the Role

Moda Health is seeking a dedicated Medical Claims Processor I to join our remote team and contribute to our mission of building a better future for healthcare. In this role, you will play a vital part in our operations by ensuring the accurate and timely resolution of medical claims, providing our members with the compassionate support and outstanding coverage they deserve. As a company founded on a commitment to quality and diversity, we invite you to bring your unique perspectives to a team that values innovation and community. This is a full-time, work-from-home position designed for a detail-oriented professional who thrives in a structured, high-volume environment while maintaining a focus on accuracy and quality.

As a Medical Claims Processor, you will be responsible for utilizing company resources efficiently to enter, review, and resolve simple to moderately complex medical claims. You will act as a key link in the healthcare lifecycle, ensuring that policies and procedures are followed to the letter while maintaining the high standards of performance that Moda Health is known for. This position offers a standard 37.5-hour work week, providing a balanced schedule that allows you to excel professionally from the comfort of your home office.

Your primary objective is the seamless adjudication of medical claims to meet company, state, and contractual regulations. Key duties include:

• Entering claim data into the system while interpreting complex medical coding and terminology related to diagnoses and procedures.
• Reviewing and analyzing moderately complex claims to resolve discrepancies through the utilization of available internal resources.
• Analyzing and applying plan concepts to specific claims, including deductibles, coinsurance, copayments, and out-of-pocket maximums.
• Examining claims to determine if further investigation is required from other departments and routing those claims appropriately.
• Releasing claims by strict deadlines to ensure compliance with state regulations and group performance guarantee standards.
• Reviewing internal Policies and Procedures (P&Ps) to ensure processing instructions are followed accurately and suggesting improvements for workflow efficiency.
• Collaborating internally with Customer Service, Membership Accounting, and Appeals departments to support broader client needs.
• Maintaining a high degree of discretion and confidentiality in compliance with federal, state, and departmental HIPAA guidelines.
• Participating in a flexible schedule that may include five hours of overtime on pre-determined Saturdays to meet fluctuating business needs.

We are looking for candidates who are highly organized, punctual, and possess a strong analytical mind. To be successful in this role, you should meet the following requirements:

• A High School diploma or equivalent is required.
• 6-12 months of experience in data entry or a medical office environment is strongly preferred.
• Proficiency in 10-key data entry with a minimum speed of 135 strokes per minute (spm).
• A minimum typing speed of 35 words per minute (wpm).
• Knowledge of medical terminology, CPT codes, and ICD-9/10 codes is preferred.
• Previous experience working with the Facets platform is considered a significant plus.
• Demonstrated ability to maintain balanced performance in both production volume and quality of work.
• Strong analytical reasoning skills and the flexibility to adapt to changing guidelines.
• Professional and effective written and verbal communication skills for internal and external collaboration.
• The ability to navigate multiple screens and maintain focus during extensive PC and keyboard work.

Moda Health is committed to providing a comprehensive benefits package that supports the health and well-being of our employees. Our benefits include:

• Competitive hourly pay range of $17.34 - $19.41, based on experience and qualifications.
• Comprehensive Medical, Dental, Vision, and Pharmacy coverage.
• Life and Disability insurance for long-term security.
• 401(K) retirement plan with company matching contributions.
• Flexible Spending Accounts (FSA) for healthcare and dependent care.
• A robust Employee Assistance Program (EAP) to support mental and emotional well-being.
• Generous Paid Time Off (PTO) and company-paid holidays.
• A supportive work culture that values diversity, inclusion, and equal opportunity for all.

Required Skills