Lead Medicaid CSR - Internal Applicants Only
14 days ago
Milwaukie
Job Description Let’s 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, 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. Position Summary The Lead Customer Service Representative provides empathetic, accurate service to members of Medicaid benefit plans in a dynamic, high-volume environment. This role analyzes callers’ needs and delivers timely, accurate responses. Additionally, the Lead supports the Medicaid supervisor and department with training, projects, and other tasks. This position requires availability Monday through Friday, 7:30 a.m. to 5:30 p.m., with occasional holiday coverage. 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. Benefits: • Medical, Dental, Vision, Pharmacy, Life, & Disability, • 401K- Matching, • FSA, • Employee Assistance Program, • PTO and Company Paid Holidays Required Skills, Experience & Education: • 1-2 years of experience as a Moda Medicaid CSR II or equivalent. External applicants must have prior experience in claims processing, call center, pharmacy, or medical/dental office., • Thorough knowledge of Medicaid plans (EOCCO and OHSU HS IDS), OHA guidelines/OARs, and claim processing. Understanding of OHA requirements and Moda administrative policies affecting pharmacy and medical claims., • Practical knowledge of medical and pharmacy terminology preferred and familiarity with diagnosis and procedure coding desired., • Technical proficiency with pharmacy and medical applications and resources, including Facets, PBM systems (Banjo, Navitus), and Content Manager with the ability to serve as a unit subject matter expert., • Keyboarding and numeric entry skills: minimum 25 wpm typing and 10-key speed of 105 spm net., • Excellent communication skills with the ability to interact professionally and handle complex calls and benefit issues independently., • Strong analytical, problem-solving, and decision-making skills with the ability to resolve complaints, correct errors, and maintain confidentiality., • Ability to organize work, meet deadlines, and manage multiple priorities under pressure., • Maintain attendance at or above company standards., • Demonstrated ability to comply with company policies and procedures., • Answer claim and benefit inquiries from callers, walk-ins, and CSRs for both Medicaid lines of business (EOCCO and OHSU HS IDS). Provide accurate solutions, confirm eligibility, and explain benefits and plan coverage. Communicate with physicians, dentists, hospitals, pharmacies, and other providers as needed to obtain or share information., • Support the unit supervisor by monitoring absences and overtime, evaluating performance, conducting training (individual, classroom, and virtual), orientation, and one-on-one meetings with CSRs. Assist with hiring and disciplinary processes., • Answer calls within OHA service level guidelines. Provide timely follow-up and return calls when these are required., • Answer Medicare Part A, B, C and D questions accurately and within CMS time frames when related to Medicaid plans., • Apply OHA Grievance, Appeals and Coverage Determination processes accurately., • Resolve and record complaints, appeals, and grievances for Medical and Pharmacy within Medicaid guidelines., • Exercise judgment and initiative to request claim adjustments required when errors or new information arise, ensuring accurate benefit calculations., • Place Pharmacy Benefit Manager overrides as outlined in Pharmacy user manuals., • Assist the supervisor by organizing and delegating tasks to complete OHA-related projects on time (e.g., member outreach projects, review and update or creation of department policies and procedures)., • Stay current on new and revised benefit information, claim processing procedures, and changes to Medicaid formularies and prescription benefits., • Complete more complex projects as directed by supervisor., • Perform other duties as assigned. 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 Medicaid and Pharmacy Operations, Claims, Sales, Sales and Account Services, Membership Accounting, Benefit Configuration, Information Services, BSA’s, 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 our email. #INTONLY
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