Health Navigator I

Moda Health•Milwaukie, OR

1d•Remote

About The Position

Provides phone, email and chat-based customer service to members of certain Performance Guarantee (PG) and Moda 360 groups by analyzing caller’s needs and providing timely and accurate responses. Answers inquiries from policyholders, members, agents, providers, hospitals, pharmacists, dentists and others regarding a wide variety of issues and questions related to a member’s benefits and health program options. This position requires staff to be flexible with their work schedule to meet the client’s needs. This is FT WFH role. Pay Range $21.30- $23.96, DOE. Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Requirements

High school diploma or equivalent.
Ability to complete training as a Customer Service Representative with Moda Health.
Claim processing experience, prior customer service experience or other related experience such as medical/dental office or pharmacy preferred.
Practical knowledge of medical, dental and/or pharmacy terminology desired.
Knowledge of diagnosis and procedure coding helpful.
Excellent oral and written communication skills.
Ability to interact professionally, patiently, and courteously with customers over the phone and in writing.
Excellent analytical, problem solving and decision-making skills.
10-key proficiency of 105 kpm net on a computer numeric keypad.
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 excellent attendance and punctuality.
Maintain confidentiality and project a professional business presence.
Ability to work with multiple applications across multiple monitors at once and learn new applications as needed.
Experience using Microsoft Office products including Outlook, OneNote and Teams.
Experience with TriZetto Facets helpful.
Ability to learn independently and take initiative to constantly improve skills.
Though open to both internal and external candidates, internal candidates must be Fully Meeting performance expectations in their current position.
Exceeding in Accuracy and Customer Service Skills is preferred.
Complete Effortless Experience training and certification after hire.

Nice To Haves

Claim processing experience, prior customer service experience or other related experience such as medical/dental office or pharmacy preferred.
Practical knowledge of medical, dental and/or pharmacy terminology desired.
Knowledge of diagnosis and procedure coding helpful.
Experience with TriZetto Facets helpful.
Internal candidates must be Fully Meeting performance expectations in their current position.
Exceeding in Accuracy and Customer Service Skills is preferred.

Responsibilities

Handle medical, dental or pharmacy inquiries or a combination of two of these, depending on existing skills and training.
Answer medical, dental and/or pharmacy claim, authorization and benefit questions from customers on specific groups.
Provide solutions to problems, confirm eligibility and explain benefits and plan coverage.
Handle inquiries received via phone, email, voicemail and/or online chat.
Respond to members via phone, online chat, SMS and email.
Complete detailed research and follow-up as needed.
May include use of multiple resources, contact with internal departments and multiple phone calls to providers, pharmacies and other carriers to resolve a situation completely.
Work with internal departments via email, phone or meetings to resolve member issues and ensure clear communication of the member’s needs.
Repeatedly analyze situations and communicate effectively in a fast-paced environment that includes working with frustrated or angry callers.
Use the Moda 360 Navigator Console to review recommended health actions and programs, recommend programs based on personalized member data and assist members in understanding and setting up programs or completing recommended health actions.
Use multiple resources simultaneously to research member issues. These could include Facets, Benefit Tracker, Content Manager, eviCore portal, Navitus, CoverMyMeds, Moda 360 Navigator Console and other internal and external websites depending on the line(s) of business.
Provide complete and accurate information in a professional manner both verbally and in writing.
Talk on the phone or respond via chat while simultaneously researching the caller’s questions and documenting the interaction.
Apply mathematical skills to determine correct benefit and claim information and manually calculate and update dental incentive levels when needed.
Exercise judgment, initiative, and discretion with confidential and sensitive subject matter.
Provide thorough resolution when at all possible for members by using critical thinking skills, extending yourself and reducing effort on the part of the caller. This could include reaching out to internal and external sources (including service providers) to assist in resolving the issue for the member and making multiple follow-up calls to the member until the issue is resolved.
Review, update and become familiar with new and revised benefit information.
Build and maintain proficiency in claim processing procedures to determine whether a claim was processed or adjusted correctly.
Communicate reasoning to callers in language appropriate to the caller’s experience level.
Request claim adjustments required due to processing or configuration errors or new information and determine which incorrect processing is the result of a configuration error versus a processing error.
When a configuration error is encountered, communicate with leadership to have it corrected.
Identify confusing or incomplete information in all internal and external resources, plan documents and member communications and make suggestions for improvements.
Update and enter primary care physician selections based on plan benefits (medical only).
Complete provider searches that may include calling several providers to locate providers who are in-network, available and meet the member’s care needs.
Work with internal departments to help resolve member gaps in care when possible, including work with the Healthcare Services or Pharmacy teams on exceptions and authorizations for those trained in medical or pharmacy, respectively.
Advocate on behalf of members when they encounter issues with obtaining covered care or medications from providers and/or pharmacies.
Place overrides to allow pharmacies to dispense medication at the point of service when appropriate based on plan details and internal policies (pharmacy only).
Address and explain complaints, appeals, and grievances.
Provide customer service to walk-in members.
Send emails or text messages to members to follow up on call details or provide forms, website links or other plan documents.
Send faxes to providers to allow them to submit medication authorization requests (pharmacy only).
Provide timely follow up and return calls when these are required.
Answer calls within PG service level agreement.
Complete continuing education on excellent customer service skills.
Perform other related duties and projects as assigned by lead, supervisor or manager.