Government Programs Customer Service Representative - #20102024

Moda Health


Date: Dec 8, 2021
City: Milwaukie, OR
Contract type: Full time
Moda Health

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 is currently has openings for Government Programs Customer Service Representatives who will provide customer service to members to Medicare, Medicaid and PERS benefit plans by analyzing caller's needs and providing timely and accurate responses; answer calls from policyholders, members, agents, providers, hospitals, pharmacists, and others regarding benefits and other issues. This position requires open availability 7am-8pm, 7 days a week.


This position is currently full time work from home due to COVID.


Primary Functions:

1. Answers pharmacy and medical claim benefit questions from callers on Medicare products. Provide solutions to problems, confirm eligibility, explain benefits and/or plan coverage, and prescription drug benefits.

2. Ability to repeatedly analyze situations, communicate effectively, in a fast paced environment that includes dealing with angry people.

3. Provide accurate information in a professional manner.

4. Apply mathematical skills to determine correct benefit information.

5. Exercise judgment, initiative, and discretion in confidential and sensitive matters.

6. Apply the Annual Notice of Change and Evidence of Coverage guidelines consistently.

7. Performs related duties:

  • Review, update and become familiar with new and revised benefit information or claim processing procedures.
  • Review and become familiar with changes in Medicare formularies and prescription benefits.
  • Accurately apply CMS Grievance, Appeals and Coverage Determination processes.
  • Update and enter primary care physician selections.
  • Request claim adjustments required because of error or new information.
  • Resolve and record complaints, appeals, and grievances for Medical and Pharmacy within Medicare guidelines.
  • Provide customer service to walk-in members.
  • Contact physicians, dentists, hospitals, pharmacies and other providers when necessary to answer questions and obtain or provide information.
  • Provide timely follow up and return calls when these are required.
  • Answers calls within CMS service level guidelines..
  • Finalize member issues within Medicare turn-around-time guidelines.
  • Answer callers’ Medicare Part A, B, C and D questions accurately and within CMS

time frames.

8. Perform other related duties as assigned.


Are you ready to be a betterist?



If you’re ready to make a difference that matters, we want to hear from you. Because it’s time to discover what’s possible.



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


01. High school diploma or equivalent
02. Practical knowledge of medical and/or pharmacy terminology desired
03. Knowledge of diagnosis and procedure coding desired
04. Claim processing experience or prior customer service experience or other related experience such as medical/dental office or pharmacy experience
05. Excellent oral and written communication skills. Ability to interact professionally, patiently, and courteously with customers over the phone and in person
06. Good analytical, problem solving and decision-making skills
07. 10-key proficiency of 105 spm net on a computer numeric keypad
08. Type a minimum of 25 wpm net on computer keyboard
09. Ability to work well under pressure in a complex and rapidly changing environment.
10. Ability to come into work on time and on a daily basis
11. Maintain confidentiality and project a professional business presence and appearance
Empathy/passion for working with senior, disable, low income populations
12. Ability to work with multiple Pharmacy and Medical applications.

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