Medical Claims Processor I

About the Role

The role requires a high degree of organization, flexibility, and attention to detail, as you will be working in a fast-paced environment with multiple priorities and deadlines. Your ability to maintain confidentiality and handle sensitive information with discretion is essential, as you will be working with confidential patient data and company information.

The Medical Claims Processor I role is an excellent opportunity for those looking to start or advance their career in the healthcare industry, with opportunities for professional growth and development within the company.

What You Will Do

• Enter claims data into the system while interpreting coding and understanding medical terminology in relation to diagnosis and procedures
• Review, analyze, and resolve claims through the utilization of available resources for moderately complex claims
• Analyze and apply plan concepts to claims that include deductible, coinsurance, copay, out of pocket, etc.
• Examine claims to determine if further investigation is needed from other departments and route claims appropriately through the system
• Adjudicate claims to achieve quality and production standards applicable to this position
• Release claims by deadline to meet company, state regulations, contractual agreements, and group performance guarantee standards
• Review Policies and Procedures (P&P'S) for process instructions to ensure accurate and efficient claims processing
• Provide suggestions for potential process improvements
• Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, state, and departmental confidentiality guidelines
• Work a flexible schedule that may include working 5 hours of overtime on pre-determined Saturdays to meet business needs

What We Are Looking For

• High school diploma or equivalent
• 6-12 months of data entry or medical office experience
• 10-key proficiency of 135 spm
• Type a minimum of 35 wpm
• Knowledge of medical terminology, CPT codes, and ICD-9/10 codes
• Demonstrated work habits that include punctuality, organization, and flexibility
• Ability to maintain balanced performance in areas of production and quality
• Analytical reasoning and flexibility
• Professional and effective written and verbal communication skills
• Experience with Facets platform (a plus)
• Ability to work in a remote environment with minimal supervision

Nice to Have

• Experience working in a healthcare setting
• Certification in medical coding or billing
• Knowledge of healthcare regulations and laws
• Experience with claims processing software

Benefits and Perks

• Medical, dental, vision, pharmacy, life, and disability insurance
• 401K matching
• Flexible spending account (FSA)
• Employee assistance program
• Paid time off (PTO) and company-paid holidays
• Opportunity to work from home and contribute to a company that values diversity and inclusion
• Professional development and growth opportunities within the company
• Access to cutting-edge technology and software
• Collaborative and dynamic work environment

• When applying, make sure to highlight your experience with medical terminology and data entry skills, as these are essential for the role.
• Familiarize yourself with the Facets platform, as experience with this software is a plus.
• Be prepared to provide examples of your analytical reasoning and flexibility in your previous roles.
• Showcase your ability to work in a remote environment with minimal supervision, and highlight any experience you have with claims processing software.
• Research the company culture and values, and be prepared to discuss how your own values align with those of Moda Health.
• Consider including any relevant certifications, such as medical coding or billing, to stand out from other applicants.
• Prepare to discuss your knowledge of healthcare regulations and laws, and how you have applied this knowledge in previous roles.