Dental Claims Support I

Moda Health•Milwaukie, OR

2d•Hybrid

About The Position

Moda Health is hiring a Dental Claims Support I for a full-time hybrid position based in Milwaukie, Oregon. The role provides backup to support leads, including staff training, and handles complex file reviews, claims adjustments, and Coordination of Benefits (COB) claims. The position also supports reports, member accumulators, deductible credits, provider updates, overpayment recovery, stop payments, and void checks. The successful candidate will process claims and adjustments for Medicare, Oregon Health Plan, commercial group, and individual plans while following compliance requirements, contractual terms, administrative policies, internal procedures, and market conduct guidelines. The role communicates with members, providers, other insurance carriers, and internal departments; documents work; reviews claim files; responds to customer service issues; and assists with audits, reports, and process improvements. The position is based in an office environment and involves extensive computer and keyboard use, prolonged sitting, and frequent telephone communication. A reliable, high-speed, hard-wired internet connection is required to support remote or hybrid work. The employee must be comfortable using multiple computer screens and being on camera for virtual training and meetings. Work beyond the standard workweek, including evenings and occasional weekends, may be required to meet business needs.

Requirements

High school diploma or equivalent.
One or more years of experience working with insurance claims.
Strong reading, writing, and verbal communication skills.
Ability to handle complex support functions accurately and on time.
Ability to back up all Claim Support functions and accept additional responsibilities while maintaining the current workload.
Ability to work under pressure with frequent interruptions and shifting priorities.
Analytical, problem-solving, organizational, and detail-orientation skills.
Ability to accurately track refund money and post it to the correct member, provider, and group accounts.
Ability to review files, analyze results, and organize multiple adjustments and/or accumulator updates.
Ability to accurately track and request appropriate funds to be reissued to members and providers.
Ability to maintain balanced performance meeting expectations for production and quality.
Meet or exceed company attendance standards.
Reliable, high-speed, hard-wired internet connection to support remote or hybrid work.
Comfort using multiple computer screens and being on camera for virtual training and meetings.

Responsibilities

Provide backup to support leads, including training staff.
Investigate complex file reviews and process complex claims adjustments and Coordination of Benefits (COB) claims.
Handle phone calls, overpayment recoveries, stop payments, and void checks.
Sort, assign, and work reports, including building member accumulators, giving deductible credits, and adjusting claims for provider updates.
Follow compliance rules when processing claims, including requesting refunds and issuing additional benefits for Medicare, Oregon Health Plan, commercial group, and individual plans.
Document work clearly and concisely according to internal procedures and market conduct guidelines, and analyze existing file notes and documentation.
Interpret requests from members, providers, and internal departments to ensure they comply with contractual and administrative guidelines.
Communicate by telephone with members, providers, and other insurance carriers.
Send custody, primary payment, refund request, and other form letters in a timely manner.
Perform basic and complex adjustments on previously processed claims using Facets claims and CS tasks, Content Manager workbaskets, NEA Fast-Attach, emails, and reports.
Investigate and process COB claims in a timely manner and update information as required.
Review User Procedure Manuals for process instructions and suggest potential improvements.
Identify trends in systems and procedures and recommend improvements to increase efficiency and reduce errors.
Review claims files in detail to determine overpayments or underpayments and back up claims processing and training units when needed.
Respond to and follow up on Customer Service tasks and issues.
Monitor logs with manually tracked offsets for ASO prepay claims.
Assist with gathering data for group audits.
Perform high-level reviews of clinical chart notes for relevancy.
Perform other assigned duties, including department reports and projects.