Lead Health Navigator - Internal Applicants Only

Moda Health

Posted on : 13-04-2025

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1 Vacancy

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Job Location

Milwaukie, OR - USA

Hourly Salary

$ 27 - 34

Vacancy

1 Vacancy

Posted on : 13-04-2025

Job Description

Lets do great things together!

About Moda
Founded in Oregon in 1955 Moda is proud to be a company of real people committed to quality. Today like then were 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. Lets be better together.

Position Summary
Provides phone email SMS and chatbased customer service to members of certain Performance Guarantee (PG) and Moda 360 groups by analyzing callers needs and providing timely and accurate responses. Answers inquiries from policyholders members agents providers hospitals pharmacists dentists and others regarding a wide variety of issues and questions related to a members benefits and health program options. Supports Health Navigator team and supervisor. This is FT WFH role.

Pay Range
$27.49 $34.36 hourly (depending on experience)
**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.

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 12 years of experience at Moda (or equivalent experience outside of Moda) providing customer service in Medical Dental and/or Pharmacy Customer Service. CSR II or department equivalent preferred. Health Navigator experience strongly preferred.
Ability to meet and exceed all department standards and coach staff members to meet standards as well.
Strong verbal writing and interpersonal skills.
Experience projecting empathy/passion for working with all customers and coworkers.
Strong analytical problem solving and decisionmaking skills with demonstrated ability to independently handle and resolve complaints correct errors and resolve issues in accordance with Moda policies.
10key proficiency of 105 kpm net on a computer numeric keypad.
Type a minimum of 25 wpm net on computer keyboard.
Ability to become a unit expert on online resources and applications including Facets Benefit Tracker Content Manager MedAccess/Navitus CoverMyMeds Moda 360 Health Navigator Console MS Teams OneNote and others.
Ability to work well under pressure while providing excellent customer service and helping the unit meet all service levels.
Thorough knowledge of all groups assigned.
Thorough knowledge and understanding of requirements and Moda administrative policies effecting medical dental and pharmacy claims.
Ability to maintain confidentiality and project a professional business presence and appearance.
Ability to back up supervisor answer questions from CSRs assist in training and complete reports.
Demonstrated ability to consistently organize work and time to meet deadlines and complete work in a timely manner.
Ability to maintain excellent attendance and punctuality and request time off with advance notice.
Demonstrated ability to comply with company rules and policies and project a positive and accepting attitude.
Completed Effortless Experience course and certification or ability to complete soon after hire.

Primary Functions:

Provide back up and support to supervisor of unit. This includes monitoring absence and overtime monitoring phone line service levels evaluating performance training (individual and classroom) orientation and oneonones with Health Navigators. Assist in the hiring process and the employee disciplinary process.
Answer medical dental and pharmacy claim and benefit questions from internal and external customers and team members on Moda 360 dedicated groups. Act as a primary resource for all departments on questions and issues relating to these groups. Maintain knowledge in standard CS groups in order to assist those teams.
Handle escalated calls and issues from various sources including incoming calls from customers and emails from internal departments.
Assign work to staff as needed including projects outreach requests and task lists.
Gather and communicate monthly performance metrics and audit results to each staff member timely and completely.
Review any rebutted audit results listening to the call as needed. Explain the rationale behind the audit or send to the Auditing team for review based on the outcome.
Monitor Facets ToDo list email inboxes and MS Teams chat regularly and prioritize questions and requests in order to meet the needs of staff members their callers and other departments.
Repeatedly analyze situations and communicate effectively in a fastpaced environment that includes working with frustrated or angry callers.
Use multiple resources simultaneously to research member issues or questions from staff including Facets Benefit Tracker Content Manager eviCore portal Navitus CoverMyMeds and other internal and external websites.
Monitor phone and chat lines to assist in handling these contacts during periods of high volume.
Provide accurate information timely and in a professional manner both verbally and in writing.
Apply mathematical skills to determine correct benefit information and accurate customer service statistics.
Exercise judgment initiative and discretion with confidential and sensitive subject matter.
Provide thorough resolution when at all possible for members by using critical thinking skills extending yourself and reducing effort on the part of the caller. This could include reaching out to internal and external sources (including service providers) to assist in resolving the issue for the member.
Assist team members in determining the best course of action and next steps for resolving caller issues focusing on providing resources and support to allow them to better resolve issues independently in the future.
Demonstrate empathy and respect for all team members and support positive communication within the team.
Perform related duties:
- Review update and become familiar with new and revised benefit information and communicate to staff.
- Build and maintain proficiency in claim processing procedures to determine whether a claim was processed or adjusted correctly. Communicate reasoning to callers and Health Navigators in language appropriate to experience level.
- Request claim adjustments required due to processing or configuration errors or new information and determine which incorrect processing is the result of a configuration error versus a processing error. When a configuration error is encountered communicate with the appropriate department to have it corrected.
- Identify confusing or incomplete information in all internal and external resources plan documents and member communications and make suggestions for improvements.
- Complete provider searches that may include calling several providers to locate providers who are innetwork available and meet the members care needs.
- Work with internal departments to help resolve member gaps in care when possible including work with the Healthcare Services or Pharmacy teams on exceptions and authorizations.
- Advocate on behalf of members when they encounter issues with obtaining covered care or medications from providers or pharmacies.
- Place overrides to allow pharmacies to dispense medication at the point of service when appropriate based on plan details and internal policies.
- Address and explain complaints appeals and grievances.
- Provide customer service to walkin members.
- Contact physicians dentists hospitals pharmacies and other providers when necessary to answer questions and obtain or provide information.
- Send emails or text messages to members to follow up on call details or provide forms website links or other plan documents and review Health Navigator emails for accuracy.
- Provide timely follow up and return calls when these are required.
- Answer contacts as needed to maintain PG service level agreement.
- Participate in User Acceptance Testing and workgroups as assigned.
- Attend meetings with internal and external participants at all levels. Create job aids and resources for staff and request updates to Policy and Procedure manuals.
- Monitor staff ToDo lists to ensure that they are completing tasks within department TAT send reminders and offer support as needed to keep tasks current.
- Perform other related duties and projects as assigned by supervisor or manager.

Contact with others & Primary Functions:

Inside the company with Medical Claims Healthcare Services Dental Claims Dental Provider Relations Marketing Group Integration Medical Provider Relations Pharmacy Operations Case Management and others as needed to resolve the customers issue. Outside the company with members providers pharmacies attorneys policyholders brokers service providers and other insurance carriers. May serve on committees and work with Sales Manager Directors or Vice Presidents on special projects member calls etc.
Constant sitting and telephone use. Close PC monitor and keyboard work. Must be able to handle multiple tasks simultaneously and manage time effectively. Constant interaction with others on the phone in writing and in person.

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 & Danielle Baker via our email.

#INTONLY

Employment Type

Full-Time

Company Industry

Key Skills

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About Company

Moda Health

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Lead Health Navigator - Internal Applicants Only

Moda Health

Job Description

Employment Type

Company Industry

Key Skills

About Company

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