About the Role
Are you a detail-oriented professional with a passion for healthcare excellence and a commitment to accuracy? Moda Health is seeking a dedicated Medical Claims Support I specialist to join our remote team. Since our founding in 1955, Moda has been a company of real people committed to quality, diversity, and the well-being of our community. In this critical role, you will contribute to building a better future for healthcare by ensuring our members receive the compassionate support and precise claims processing they deserve. This is a full-time, work-from-home position that offers you the opportunity to grow your career within a supportive and inclusive organization.
As a Medical Claims Support I specialist, you will be responsible for investigating and processing claim adjustments across all medical lines of business, including Medicare and Medicaid plans. You will serve as a vital link between administrative policy and member satisfaction, ensuring that every adjustmentwhether related to overpayment recovery, underpayment corrections, or Coordination of Benefits (COB)is handled with the utmost care and professionalism. This role is perfect for a self-motivated individual who thrives in a structured, fast-paced environment and enjoys solving complex puzzles within the healthcare landscape.
Key Responsibilities- Perform basic and moderately complex claim adjustments within the Facets system while interpreting medical coding, diagnosis, and procedure terminology.
- Review, analyze, and resolve claim issues by utilizing internal resources and applying plan concepts such as deductibles, coinsurance, copays, and out-of-pocket maximums.
- Investigate Coordination of Benefits (COB) for Medicare and Medicaid plans, ensuring file reviews are accurate and updates are performed timely.
- Handle overpayment recoveries and underpayment adjustments, including the issuance of adjustment-related letters to both members and providers.
- Manage financial tasks such as performing payment offsets, validating stop payment requests, and processing voided or manual checks.
- Examine claims to determine if further investigation is required from other departments and route them appropriately to maintain high quality and production standards.
- Maintain unit inventory through proactive monitoring of refunds, telephone inquiries, and system reports.
- Communicate effectively via telephone and email with claimants, policyholders, providers, and other insurance carriers to resolve discrepancies.
- Document all actions thoroughly in accordance with internal procedures and market conduct guidelines to ensure compliance and transparency.
- Provide essential backup support to Medical Customer Service and COB departments when business needs require additional assistance.
- High school diploma or equivalent educational background is required.
- Minimum of 6 months of experience in medical claim processing or customer service involving multiple plan types, with a proven track record of exceeding performance levels.
- At least 12 months of experience as a Processor I with consistent high-level performance results is preferred.
- Professional written and verbal communication skills with the ability to maintain a professional business image at all times.
- Exceptional technical proficiency, including a 10-key speed of 135 wpm net and a typing speed of at least 35 wpm net on a computer keyboard.
- Strong analytical, problem-solving, and decision-making skills with a high degree of attention to detail.
- Proficiency in claims processing systems, specifically Facets, alongside Microsoft Word and Excel.
- Demonstrated ability to multitask, meet tight timelines, and work effectively under pressure while maintaining confidentiality.
- Must have a reliable, high-speed, hard-wired internet connection and be comfortable being on camera for virtual training and meetings.
- Flexibility to work in excess of the standard workweek, including evenings and occasional weekends, to meet business demands.
- Competitive hourly pay range of $21.30 - $23.96, depending on experience and qualifications.
- Comprehensive health coverage including Medical, Dental, Vision, and Pharmacy benefits.
- Financial security through Life and Disability insurance and a 401K plan with company matching.
- Flexible Spending Account (FSA) and an Employee Assistance Program (EAP) to support your well-being.
- Generous Paid Time Off (PTO) and company-paid holidays to ensure work-life balance.
- A remote work environment that values diversity, inclusion, and the unique perspectives of every employee.
Moda Health is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. If you share our commitment to building healthy spaces and providing outstanding healthcare coverage, we invite you to apply and help us be better together.