Moda Health Appeal Coordinator, Government Programs - Temp $13/hour in Portland, Oregon

Appeal Coordinator, Government Programs - Temp $13/hour

Job Title

Appeal Coordinator, Government Programs - Temp $13/hour


Open until filled





Other Location

Job Class: Temp


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.

We are seeking a temporary Appeal Coordinator in our Appeal Government Programs team. This position will investigate and respond to medical, pharmacy and dental member grievances, complaints, appeals, and inquiries for the organization. Process medical, pharmacy and dental state insurance divisions and Better Business Bureau inquiries.

Primary Functions:01. Process all member and individual grievances, complaints and appeals. Perform a complete review and investigation at each stage of the complaint/appeal process and ensure the appropriate documentation.02. Respond in writing to requests, grievances, complaints, and appeals within the mandated timeframes.03. Communicate effectively with other departments such as Claims and Customer Service, Billing & Eligibility, Medicare and Medicaid Compliance, Medicare Operations and Programs, Medicaid Services, Dental Professional Relations, Medical Professional Contracting and Healthcare Services to ensure complete and fair reviews of grievances, complaints and appeals. 04. Communicate by letter and/or telephone with members, claimants, independent review entities, attorneys, and providers regarding claims/policies on Moda Health benefit plans.05. Interpret contracts (evidence of coverage; handbooks) and determine actions required.06. Respond to independent review entity requests for member case files within the stipulated timeline and ensure appropriate documentation required for reporting.07. Work with Claims Support to adjust previously processed claims and with Healthcare Services and Pharmacy Services to adjust previously processed prior authorizations. 08. Perform total claim review to determine over/underpayment on problem claims.09. Research and respond to member correspondence.10. Send grievance/appeal acknowledgement letters.11. Document accurately in Facets regarding outcome of grievances, complaints and appeals.12. Data enter member/individual grievance, complaint and appeal files into the appropriate Access databases.13. Other 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.

Required Skills

  1. High School diploma or equivalent

  2. 1-2 years experience as a Sr. Claim Support Specialist or Customer Service Rep.

  3. Demonstrated knowledge with CMS rules for Medicare and Medicaid grievance, complaint and appeal processes preferred.

  4. Demonstrated knowledge of multiple benefit plans and Moda Health administrative policies, products, and business lines.

  5. Demonstrated strong reading, verbal, written and interpersonal communication skills.

  6. Demonstrated initiative, analytical, problem solving and organizational skills.

  7. 10 key proficiency of 105 strokes per minute on a computer numeric keypad.

  8. Type a minimum of 25 words per minute on a computer keyboard.

  9. Demonstrated proficiency in computer applications such as Word, Access, Excel and operating systems, such as Facets.

  10. Ability to work well under pressure, meet deadlines and produce a high volume of work.

  11. Ability to read and interpret contracts and apply Moda Health policies and procedures.

  12. Knowledge and understanding of complaint and appeal procedures.

  13. Ability to maintain confidentiality and project a professional business image.

  14. Proficiency in Moda Health operating systems.

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

  16. Ability to communicate positively, patiently and courteously.