Lead Medicare CSR Internal Applicants Only

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 customer service to members of Medicare and PERS benefit plans by analyzing callers needs and providing timely and accurate responses. Answers calls from policyholders members agents providers hospitals pharmacists and others regarding benefits or other issues This is a FT WFH role.


Pay Range
$27.49- $30.92 hourly DOE.
*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:

• High school diploma or equivalent.
• 1-2 years of experience as a Moda CSR IV designation may also be obtained through equivalent work experience and knowledge level at Moda or when recruiting externally.
• Claim processing experience or prior customer service experience or other related experience such as medical/dental office or pharmacy experience.
• Practical knowledge of medical and/or pharmacy terminology desired.
• Knowledge of the diagnosis and procedure coding desired.
• Excellent oral and written communication skills. Ability to interact professionally patiently and courteously with customers over the phone and in person.
• Good analytical problem solving and decision-making skills.
• 10-key proficiency of 105 net on a computer numeric keypad.
• Type a minimum of 25 wpm net on computer keyboard.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Ability to maintain confidentiality and project a professional business presence and appearance.
• Ability to backup 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 on a timely basis.
• Empathy/passion for working with senior disabled low-income populations
• Ability to work with multiple Pharmacy and Medical applications.
• Ability to become the unit expert on online resources including Facets the PBM system (MedAccess & Navitus) and Content Manager.
• Strong analytical problem solving and decision-making skills with demonstrated ability to handle and resolve complaints correct errors and resolve issues
• Knowledge and understanding of OHA CMS requirements together with Moda administrative policies affecting pharmacy and/or medical claims.
• Thorough knowledge of all Medicaid Medicare Advantage Medicare Supplement and PERS plans.
• Ability to come to work on time and daily. Maintain attendance at or above company standards.
• Demonstrated ability to comply with company rules and policies.
• Demonstrated ability to handle difficult calls and benefit issues with little assistance.

Primary Functions:

• Provide back up and support to the supervisor of unit. This includes monitoring absence and overtime evaluating performance training (individual and classroom) orientation and one-on-ones with CSRs. Assists in the hiring process and the employee disciplinary process.
• Answer claim benefit questions from callers and CSRs on both Medicare Advantage and PERS plans. Provide solutions to problems confirm eligibility explain benefits and/or plan coverage.
• Ability to repeatedly analyze situations communicate effectively in a fast-paced environment that includes dealing with angry people.
• Provide accurate information in a professional manner.
• Apply mathematical skills to determine correct benefit information.
• Exercise judgment initiative and discretion in confidential and sensitive matters.
• Apply the Annual Notice of Change and Evidence of Coverage guidelines consistently.
• Complete more complex projects as directed by supervisor and/or lead.
• Assist in the direction of the supervisor to organize and delegate tasks to complete CMS-related projects on time. (For example the Daily Reconciliation Report and Outbound Enrollment Verification projects).
• Perform other duties and responsibilities as assigned.

  • Review update and become familiar with new and revised benefit information or claim processing procedures.

  • Review and become familiar with changes in Medicare formularies and prescription benefits.

  • Place PBM overrides as outlined in Pharmacy P&P.

  • Accurately apply CMS Grievance Appeals and Coverage Determination processes.

  • Update and enter primary care physician selections.

  • Request claim adjustments required because of error or new information.

  • Resolve and record complaints appeals and grievances for Medical and Pharmacy within Medicare guidelines.

  • Provide customer service to walk-in members.

  • Contact physicians dentists hospitals pharmacies and other providers when necessary to answer questions and obtain or provide information.

  • Provide timely follow up and return calls when these are required.

  • Answers calls within CMS service level guidelines.

  • Answer callers Medicare Part A B C and D questions accurately and within CMS time frames.

Working Conditions & Contact with Others:

• Office environment with extensive close PC and keyboard use constant sitting and frequent phone communication. Must be able to navigate multiple computer screens. A reliable high-speed hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek including evenings and occasional weekends to meet business need.
• Internally with Medicare and Pharmacy Operations Claims Sales Sales and Account Services Membership Accounting Benefit Configuration Information Services BSAs Customer Service and Provider Relations. Externally with members providers other insurance companies and agents.

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.

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