Lead Pharmacy CS Rep - Internal Candidates Only

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.

Job Summary

Provide customer service to members of multiple benefit plans by analyzing the callers’ needs and by providing timely and accurate responses. Answer calls from policyholders, members, agents, providers, and others regarding benefits or other issues. Review and submit correct claims to support to adjust, supports CSR’s, backs up and supports supervisor with questions, coaching, training, and reports. This is a FT WFH role.

Pay Range

$25.58 - $28.78 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:

https://j.brt.mv/jb.do?reqGK=27779268&refresh=true

Benefits

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

Required Qualifications

• High school diploma or equivalent required.
• Knowledge of pharmacy terminology, prescription drug benefits, pharmacy claims processing, and related healthcare concepts.
• One or more years of experience as a Pharmacy Customer Service Representative supporting multiple lines of business and benefit plans, or equivalent customer service experience in a healthcare environment.
• Working knowledge of all plan types, pharmacy benefits, and programs supported by the department.
• Ability to handle stressful situations while exercising sound judgment and effective decision-making skills.
• Strong organizational skills with the ability to prioritize multiple tasks and responsibilities.
• Strong verbal, written, and interpersonal communication skills.
• Strong analytical and problem-solving skills with demonstrated ability to research issues, resolve complaints, correct errors, and provide effective solutions with minimal assistance.
• Ability to communicate professionally, positively, patiently, and courteously with members, providers, pharmacies, groups, and internal customers.
• Ability to work effectively in a fast-paced environment with frequent interruptions, shifting priorities, and competing deadlines.
• Ability to support leadership by answering questions from representatives, assisting with training, and onboarding activities, providing guidance, and serving as a departmental resource.
• Demonstrated ability to consistently comply with company policies, procedures, and regulatory requirements.
• Ability to maintain confidentiality and demonstrate professionalism when handling sensitive member, provider, and company information.
• Demonstrated reliability, dependability, and commitment to attendance expectations.
• Proficiency using Microsoft Office applications, email systems, Microsoft Teams, and workforce management tools.
• Ability to effectively navigate multiple systems, databases, web-based applications, and informational resources simultaneously while assisting customers.
• Ability to review, research, and respond to a high volume of email and Teams inquiries while maintaining accuracy, professionalism, and established service standards.
• Ability to learn and adapt to changing benefit plans, pharmacy programs, policies, procedures, and technology systems.
  
  

Primary Functions

• Provide backup and support to the unit supervisor. This includes assessing performance, monitoring calls, providing training and orientation, and participating in question-and-answer sessions for CSR I, II, and III representatives.
• Handle difficult telephone calls and complex contract-related issues.
• Provide accurate information in a professional manner.
• Assist, at the supervisor's discretion, with responding to calls and inquiries directed to the supervisor.
• Ensure the supervisor is aware of CSR feedback and concerns within the unit.
• Monitor NICE InContact and other workforce management tools to determine staffing needs and whether additional phone coverage is required.
• Provide backup phone coverage as needed or requested by the supervisor.
• Analyze situations effectively and communicate professionally in a fast-paced environment, including interactions with upset or challenging callers.
• Assist Sales and Account Services by providing member and benefit information and supporting service-related inquiries.
• Provide backup support to the Pharmacy Customer Service Trainer as needed.
• Apply mathematical skills to determine accurate benefit information.
• Exercise judgment, initiative, and discretion when handling confidential and sensitive information.
• Review, update, and maintain knowledge of new and revised benefit information, policies, and claim processing procedures.
• Answer claims and benefit questions for both group and individual products. Provide solutions to problems, confirm eligibility, and explain benefits and plan coverage.
• Review, research, and respond to a high volume of member, provider, group, and internal inquiries received through email, ensuring timely, accurate, and professional communication.
• Provide real-time support and guidance to CSR staff through Microsoft Teams chat and other communication channels.
• Provide CSR adherence on a weekly basis and CSR stats monthly.
• Assist with answering a high number of emails and keeping track of outstanding inquiries.
• Perform other duties as assigned.
  
  

Working Conditions & Contact With Others

• Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens. Must be able to find benefit information on multiple groups and plans.
• Internally: Claims, Sales and Account Services, Benefit Configuration, Provider Relations, Billing and Eligibility. Externally: Members, providers, attorneys’ brokers, government programs and other insurance companies. May serve on committees and work with Managers, Directors, or Vice Presidents on special projects, policyholder calls, demos, etc.
  
  

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 humanresources@modahealth.com email.

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