Clinical Claim Review Specialist

Founded in Oregon in 1955, 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.

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. Let’s be better together.

Founded in Oregon in 1955, 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.

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. Let’s be better together.

Provides support to the Medical Management team by assisting in the reviewing, researching and triaging of post service claim. Knowledgeable of utilization review processes, turnaround times, and concurrent review processes when reviewing, preparing or completing retrospective reviews. This is a FT WFH position.

$19.43 - $21.86 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

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

• Researches and triages claims routed to Healthcare Services based on guidelines.
• Determines if the plan type, ICD-10 code and CPT/HCPC code or place of service listed on the claim requires an authorization.
• Interacts with providers and provider offices to gather complete medical records information necessary for review of claim.
• Consults the RN or Supervisor on complex cases.
• Utilizes the Moda Health core systems for documentation of contact with providers and members.
• Communicates effectively with other Medical Management support staff.
• Analyze claims and encounters according to the limits of authorization, benefit plan and provider contracts.
• Effectively uses the Moda Health core systems to accurately determine eligibility, benefit plan, and physician networks associated with the member’s plan.
• Send proper correspondence to providers, members and other departments to obtain additional information necessary for the review of claims.
• Analyze authorizations for correct information, such as authorization maximums, limitations and special instructions for performance groups.
• Ensure adherence of Health Insurance Portability and Accountability Act (HIPPA) and other regulatory guidelines including privacy and security.
• Must maintain minimum production and quality audit.
• Responsible for the auditing of individual daily work for accuracy, consistency and compliance based on Moda Health policies and procedures, state, federal and CMS (Medicare) regulations.
• Identifies problems and researches alternative solutions.
• Perform data entry of…