Appeal Coordinator I

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
Investigate and respond to medical pharmacy and dental grievances complaints appeals and inquiries for the organization. Respond to outside regulatory inquiries as needed. This is a FT WFH role.

Pay Range
$20.88 $23.49 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

Required Skills Experience & Education:

1. High School diploma or equivalent.
   • 6 months to 2 years of experience of medical/dental claims processor or customer service preferred.
   • Demonstrated knowledge of CMS rules for Medicare and Medicaid grievance complaint and appeal processes preferred.
   • Knowledge and understanding of complaint and appeal procedures preferred.
2. Ability to interpret benefit contracts and/or Moda Health administrative policies products and business lines.
3. Demonstrated strong reading verbal written and interpersonal communication skills.
4. Demonstrated initiative analytical problem solving and organizational skills.
5. 10 key proficiency of 105 kspm on a numeric keypad.
6. Type a minimum of 25 wpm accurately on a computer keyboard.
7. Demonstrated proficiency in computer applications such as Word Excel or other core operating systems.
8. Ability to work well under pressure and meet deadlines while completing a high volume of work.
9. Ability to maintain confidentiality and project a professional business image.
10. Ability to adhere to Moda Health attendance policies and work assigned schedule which may include some overtime and occasional weekend and Holiday coverage.
11. Ability to communicate positively patiently and courteously.

Primary Functions:

1. Research all grievances complaints correspondence and appeals. Perform a complete review at each stage of the complaint/appeal process and ensure the appropriate documentation including claim review to determine over/underpayment.
2. Respond in writing (or orally when appropriate) to requests grievances complaints and appeals within the mandated timeframes.
3. Ability to maintain a full caseload.
4. Communicate effectively and appropriately with other departments to ensure complete and fair reviews of grievances complaints and appeals.
5. Communicate by letter and/or telephone with members claimants independent review entities attorneys and providers regarding claims/policies on Moda Health benefit plans.
6. Interpret contracts (evidence of coverage; handbooks) and determine actions required.
7. Respond to independent review entity requests for member case files within the stipulated timelines and ensure appropriate documentation required for reporting. Staff may also be required to respond to DFR requests or attend Medicaid hearings as a representative of the company.
8. Work with appropriate departments to effectuate decisions.
9. Meets the departments established production and accuracy standards for case completion.
10. Accurately document in system the outcome of grievances complaints and appeals.
11. 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. Constant shifting of priorities and daytoday duties. Occasional work in excess of 37.5 hours per week in order to meet business needs.
• Inside the company including with Medicare Programs Medicaid Services Professional Relations and Contracting Customer Service Membership Accounting Claims Legal Services Regulatory Compliance Privacy and Healthcare Services teams. Outside the company with Members Provider Offices Independent Review Entities Attorneys and contracted vendors.
  

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 email.