Job Description

Let\'s do great things, together

Founded in Oregon in 1955, ODS, now Moda, is proud to be a company of real people committed to quality. Today, like then, we\'re 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.

This position is responsible for benefit configuration and administration for all new and renewing Medical or Dental groups, with a focus plans of moderate to high complexity, including table update projects, achieving the highest possible auto-adjudication rates, while at the same time maintaining excellent quality. Maintain Enterprise Benefit Tracker (EBT) notes groups as needed to provide additional clarity to internal and external users regarding benefit specifics. Analyzes system solutions, defines and builds benefit designs, and maintains configuration within the systems

\xe2\x80\x8b\xe2\x80\x8b\xe2\x80\x8b\xe2\x80\x8bThis is a Remote PST position. We are only offering this position to candidates living in or willing to relocate to AK, AZ, FL, ID, OR, TX, WA.
Please follow the link below to apply to this position:
\xe2\x80\x8b\xe2\x80\x8bBenefits:

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Schedule:

• PST

Required Skills, Experience & Education:

Level I: * Bachelor\'s degree or equivalent work experience.

• 1 - 3 years prior Healthcare/Insurance experience
• Preferred: experience building benefits in Facets or other systems.
• Knowledge of existing claims procedures: 1-2 years as Lead Claims Processor, Claims Auditor, Customer Service Representative, or other related position in the insurance industry.
• Experience gathering business requirements for specialized groups or projects.
• Experience analyzing and recognizing potential business impacts for affected departments regarding benefit and/or contract changes and offering solutions or alternatives.
• PC proficient with good working knowledge of Microsoft Word and Excel.
• Strong system knowledge of Facets and Enterprise Benefit Tracker or equivalent Health Insurance benefits systems.
• Effective communication, both orally and in writing, with users, systems personnel, vendors, clients, and management.
• Ability to correctly interpret contracts, coupled with state and federal laws and limitations, and to convert into Facets benefit configuration.
• Experience planning, organizing, and prioritizing tasks and assignments to ensure established guidelines, timelines, and quality goals get met.
• Ability to document business processes.
• Ability to come to work on time and daily; work additional hours as needed.
• Ability to work independently, with minimal supervision.
• Maintain confidentiality and project a professional business image.

Level II: * Level one requirements met.

• Strong understanding of various governmental regulations for benefits and claims pertaining to ACA, Medicare Advantage, or Medicaid plans.
• Proven ability to handle multiple lines of business or complex and unique plans.
• Experience with Access (SQL).
• Demonstrated proficiency in knowledge and configuration experience in Medical Claims, Clinical Editing, and Utilization Management.
• Ability to audit product configuration with a high degree of accuracy and within established timelines.
• Higher problem-solving skills, approaching resolutions on their own by testing updates made to configuration in system test environments.
• Proven facilitation and conflict resolution skills.
• Ability to train new staff on benefit configuration for assigned work.
• Serve as a mentor to level 1 staff by assisting with training, answering questions, and being available as a resource.
• Demonstrates ability to meet or exceed quality expectations consistently.
• Ability to work independently, with minimal supervision.

Primary Functions: (Functions may vary depending on level)

• Knowledge of standard medical plan configuration as well as complex ASO groups, using the information provided to determine the most effective and efficient configuration to achieve the highest possible quality and auto-adjudication.
• Creates and maintains Facets benefit components and configures products for commercial standard and complex groups, spanning multiple product lines.
• Participates in meetings (both Implementation and other) representing Benefit Configuration to fully understand plan benefits and validate Facets capabilities.
• Facilitates meetings for decision making around Moda\'s handling of specific procedure and/or diagnosis codes.
• Ensures benefit configuration turnaround times are met for all work assigned.
• Answers inquiries from various internal departments regarding contract and product set-up issues on assigned business.
• Performs quality audits on benefit configuration at the direction of department management.
• Performs quality assurance testing on test claims to validate benefit configuration will meet the needs of the Claims departments.
• Evaluates and resolves benefit configuration questions via claims and email inquiries.
• Communicates product updates and changes to the company via e-mail or EBT updates.
• Assists with department projects and reports at the direction of department management
• Interprets benefit information from the group application and or contract language in order to create a product within corporate turnaround time standards.
• Demonstrates problem solving skills, by thinking \xe2\x80\x9coutside the box\xe2\x80\x9d to identify the most efficient use of the system\'s capability from a corporate perspective.
• Identifies situations where benefit configuration alone cannot fully meet the plan\'s requirements. Works with departmental management, and cross functionally, to identify the Workflow configuration and associated business processes needed.
• Is proficient and understands how medical coding and claims processing works in conjunction with the clinical editing functionality within the system.
• Documents departmental policies and business processes as assigned by department management.
• Deals tactfully and respectfully with all departments, knowing that each department brings a different view and be able to understand the differences of opinions.
• Facilitates project from beginning to end, this will include meetings, documentation and configuration of benefits.
• Participate in special projects and committees.
• Supports quality and process improvement initiatives.
• Performs other duties as assigned.

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.

For more information regarding accommodations please direct your questions to Kristy Nehler and Daniel McGinnis via our humanresources@modahealth.com email.



Pay Range

\xc2\xa445,181.50 Annually to \xc2\xa456,819.27 Annually

Moda Health