Medicare CSR III -Remote (Internal)

Customer Service Representative, Medicaid – Work from Home

Let’s do great things, 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 Health currently has openings for Medicare Customer Service Representative III. This position requires working in a hectic call center-type environment with a high volume of calls. The person in this position has interactions throughout the day with teammates, other Moda employees, and external customers. The Customer Service Representative is the initial point of contact. It provides superior customer service by demonstrating a high degree of courtesy, accuracy, and professionalism to Medicaid, Medicare, and PERS benefit plans members. In addition, this position acts as a resource for members, providers, policyholders, hospitals, pharmacists, and others by analyzing caller’s needs and providing timely and accurate responses. The position requires open availability 7 am-8 pm.

This position is currently full time work from home.

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

• PST

• High school diploma or equivalent.
• Experience as a Moda CSR II consistently performing at an overall satisfactory level of performance for a minimum of 6 months. Moda III designation may also be obtained through equivalent work experience and knowledge level at Moda. 
• Practical knowledge of medical and/or pharmacy terminology desired.
• Knowledge of diagnosis and procedure coding desired.
• Claim processing experience or prior customer service experience or other related experience such as medical/dental office or pharmacy experience.
• Excellent interpersonal, oral and written communication skills. 
• Ability to interact professionally, patiently, and courteously with customers over the phone and in person.
• Ability to articulate complex information in an easy-to-understand manner.
• Strong active listening skills and the ability to ask probing questions and understand concerns.
• Ability to work effectively with a team, and exercise sound judgment in handling assigned tasks including maintenance of strict confidentiality.
• Excellent interpersonal, written, and oral communication skills.
• Ability to demonstrate cooperation and teamwork.
• Good analytical and problem-solving skills.
• Type a minimum of 25 wpm net on computer keyboard.
• Ability to work well under pressure in a complex and rapidly changing environment. 
• Ability to maintain agreed upon work schedule.
• Maintain confidentiality and project a professional business presence and appearance.
• Empathy/passion for working with disabled and low-income populations.
• Ability to work with multiple Pharmacy and Medical applications.

1. Act as a member advocate and liaison with providers and partners as needed to ensure members are connected to services.
2. Respond to and assist members and/or providers with Physical, Mental health plan assignments.
3. Answer claims and benefit questions from callers on Medicare and Medicaid physical health, mental health, or pharmacy products.  Provide solutions to problems, research, verify and resolve eligibility queries, explain benefits and/or plan coverage and prescription drug benefits.
4. Refer Medicaid members to appropriate staff to assist with Non-Emergency Medical Transportation (NEMT) questions.
5. Collaborate with others inside and outside of Health Share to explain benefits not covered by Oregon Health Plan and provide information on community resources when appropriate.
6. Work collaboratively with Oregon Health Authority, plans, providers, and members to ensure effective and timely follow-up of specific requests, issues, and problem resolution.
7. Maintain confidentiality of information for all members.
8. Work collaboratively with vendors, plans, providers, and members to ensure effective and timely follow-up of specific requests, issues, and problem resolution and provide information on community resources when appropriate.
9. Ability to repeatedly analyze situations, communicate effectively, in a fast-paced environment that includes effective conflict resolution skills.
10. Provide accurate information in a professional manner and maintain current knowledge and skills.
11. Apply mathematical skills to determine correct benefit information.
12. Exercise judgment, initiative, and discretion in confidential and sensitive matters.
13. Provide proactive, value added service by identifying and reporting recurring issues.
14. Use current technology and software to document all activities from any mode of communication from members, providers, and other customers.
15. Cross trained onto EOCCO Medical and Pharmacy and OHSU Medicaid Medical lines of business
16. Cross trained onto Moda and PERS Supplement lines of business
17. Cross trained onto Moda and Summit Medicare Advantage lines of business
18. Cross trained onto Pharmacy Medicare line of business
19. Assist with Medicare Welcome Calls
20. Availability to work 7:00 am – 8:00pm, 7 days per week
21. Consistently exceeding Moda standards and expectations including but not limited to quality, production, and attendance.
22. Other duties as assigned.

1. Review, update and become familiar with new and revised benefit information or claim processing procedures.
2. Review and become familiar with changes in prescription benefits.
3. Accurately apply Grievance and Appeal processes.
4. Update and enter primary care physician selections.
5. Request claim adjustments required because of error or new information.
6. Provide customer service to walk-in members (if assigned and working in the office).
7. Contact physicians, dentists, hospitals, pharmacies, and other providers when necessary to answer questions and obtain or provide information.
8. Provide timely follow up and return calls when these are required.

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

Salary : $22 - $24