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Moda Health Lead Medical Claims Processor in Bend, Oregon

Lead Medical Claims Processor

Job Title

Lead Medical Claims Processor


Open Until Filled





Other Location


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 is seeking A Lead Medical Claims Processor. This role assist the Supervisor(s) and Claims Manager with daily operations. Monitors and assists claims processors and provides first line technical contact for any claims related issues. Responsible for coordinating work-flow, lead efforts in error reduction, and support team members with claim payment procedures. Will instruct others in processing procedures and/or provide general instruction related to claim adjudication. Reviews and applies the Plan policies and procedures as required for complex health benefit issues. Provides feedback to the supervisor(s) and trainer, through written and verbal documentation/communications, regarding claims issues, process improvements and other areas of concern. Demonstrates leadership ability by encouraging positive behavior and professionalism.

Primary Functions:

  • Process all types of claims handled by unit. Enter data in system from claim forms or image by use of 10-key pad and alpha keyboard. Must understand benefits, provided by specific plans, how to determine eligibility, how to determine if claim qualifies for benefits, how system should pay to ensure correct benefits are allowed and paid.

  • Reads documents and patient notes, checks and reworks pended claims for additional information or questions.

  • Analyzes claims that will not adjudicate because of system edit. Refers questionable issues to Claims Supervisor.

  • Performs manual calculation/override of benefit to enter correct information on claims the system cannot process.

  • Reviews User’s Procedural Manual (UPM), system memos and CST notes and may request additional information.

  • Consistently meets or exceeds Quality rating of “4”.

  • Consistently meets or exceeds Quantity rating of “4”.

  • Performs other duties as assigned such as assisting supervisors with question queues, high dollar queues, system queues, training other processors, COB investigation, COB claims processing or preparing reports.

  • Monitors claims inventories and make processing recommendations to the Claims Supervisor.

  • Review/Release high dollar claims.

  • Use and manipulate excel files

  • Performs other duties as assigned such as assisting supervisors with question queues, dollar queues, system queues, training other processors, COB investigation, COB claims processing or preparing reports.

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.

Required Skills

  1. High school diploma or equivalent.

  2. 1-2 years Moda Health claims processing experience preferred

  3. 10 key proficiency of 135 spm net on a computer numeric keypad.

  4. Type a minimum of 35 wpm net on a computer keyboard.

  5. Knowledge of medical terminology, HCPC codes, CPT codes and ICD-9/ICD-10 codes.

  6. Analytical, problem solving, retention of new knowledge, organizational skills.

  7. Overall Quality rating of “4” or better for 6 months or more.

  8. Production rating of “4” or better for 6 months or more.

  9. Demonstrated knowledge and understanding of plans processed by unit including complex claims and claims from various provider panels.

  10. Understanding of the Facets platform a plus.

  11. Ability and interest in training, assisting supervisor with questions from others, while

  12. still contributing to claims processed by the unit.

  13. Demonstrated ability to organize work and time to meet deadlines and complete work on a timely basis.

  14. Ability to come into work on time and on a daily basis.

  15. Demonstrated ability to comply with company rules and policies.

  16. Effective written and verbal communication skills