Medical Claims Support I

About Moda Health

Moda Health was established in Oregon in 1955 and is built around a people-first approach to quality healthcare. The organization focuses on providing strong coverage for members, supportive service for the community, and broad benefits for employees. It also emphasizes diversity, inclusion, and a workplace culture where different experiences and viewpoints are valued.

Role Overview

This position handles medical claim adjustments across all medical lines of business, including coordination of benefits (COB) adjustments for Medicare and Medicaid plans. The role also covers overpayment recovery, underpayment corrections, payment offsets, stop payment validation, file review, and adjustment-related correspondence to members and providers. The job includes supporting customer service inquiries related to contractual and administrative policies and may require phone-based assistance to complete adjustments or related support work. This is a full-time work-from-home role.

Compensation

The hourly pay range for this role is $21.30 to $23.96, depending on experience and qualifications. Candidates who meet only the minimum requirements will be considered for the lower end of the stated range.

Benefits

The company offers a benefits package that includes medical, dental, vision, pharmacy, life and disability coverage, a 401(k) matching plan, FSA, an employee assistance program, paid time off, and company-paid holidays.

Required Qualifications

Applicants should have a high school diploma or equivalent. A minimum of 6 months of experience in medical claims processing or customer service involving multiple plan and claim types is required, along with a history of meeting or exceeding performance expectations. Candidates should also have at least 12 months of experience as a Processor I performing at an exceeding level, or demonstrate equivalent knowledge and experience gained internally or through external hiring. Strong written and verbal communication skills are essential, along with fast and accurate numeric keypad entry, keyboard typing speed, organizational strength, multitasking ability, and the judgment to manage priorities under pressure. The role requires confidentiality, professionalism, analytical thinking, problem-solving, attention to detail, and solid decision-making. Familiarity with claims systems such as Facets, Word, and Excel is important, as is a strong understanding of administrative policies that affect claims and customer service. The company also expects consistent attendance, punctuality, flexibility, and a cooperative team-oriented approach.

Primary Duties

The selected candidate will process basic and moderately complex claim adjustments, interpret coding, and apply medical terminology and plan benefits to claims work. Responsibilities include reviewing and resolving claims issues using available resources, applying plan features such as deductibles, coinsurance, copays, COB, and out-of-pocket provisions, and routing claims to the correct department when additional review is needed. The role also involves meeting quality and production standards, releasing claims and adjustments by required deadlines, reviewing policies and procedures for process guidance, maintaining unit inventory, preparing refund requests and form letters, managing file reviews and accumulator updates, processing voided checks and reissued payments, handling stop payment requests, and corresponding with claimants, policyholders, providers, and other insurance carriers. Documentation must be completed thoroughly and in line with internal and market conduct requirements. Additional support may include helping with programming issues, responding through Facets, Content Manager, and email, backing up Medical Customer Service, COB, and Medical Claims teams, and completing other assigned duties. Internal contacts include Claims, Customer Service, Healthcare Services, Membership Accounting, Information Technology, and Professional Relations, while external contacts include providers, members, vendors, and insurance companies. The role may also involve committee and appeals participation.

Working Conditions

This is an office-based role performed remotely, with extensive computer and keyboard use, long periods of sitting, and frequent phone communication. The employee must be comfortable using multiple screens, have a reliable high-speed hard-wired internet connection for remote or hybrid work, and be willing to appear on camera for virtual training and meetings. Work may extend beyond the standard schedule, including evenings and occasional weekends, based on business needs.

Equal Opportunity Statement

Moda Health provides equal employment opportunities to qualified applicants regardless of race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status, or any other protected status. This applies to all employment terms, including hiring, placement, promotion, termination, layoff, recall, transfer, leave, compensation, and training. Accommodation questions may be directed to the human resources contacts listed by the employer.