Inpatient Claims Processor

Company: Moda Health
Location: Remote (FT WFH)
Pay Range: $21.30 - $23.96 hourly

About Moda:
Founded in 1955, Moda Health is a company committed to building a better future for healthcare. We focus on offering outstanding coverage to our members, compassionate support to our community, and comprehensive benefits to our employees. We value diversity and inclusion in our workplace and invite applications from candidates who share this commitment.

Position Summary:
Responsible for the timely and accurate payment of Commercial and Medicaid inpatient hospital claims. This role involves answering internal questions from various departments and responding to provider correspondence. This is a Full-Time Work From Home role.

Responsibilities:

• Review, process, and adjust Commercial and Medicaid inpatient claims.
• Interpret coding, understand medical terminology, and analyze claim data related to diagnoses and procedures.
• Price and resolve inpatient claims using available resources, including moderate to complex adjustments and file reviews.
• Process claims for all contract types (e.g., DRG, per diem, case rate, % of CMS).
• Apply plan concepts such as deductibles, coinsurance, copays, and out-of-pocket maximums.
• Examine claims to determine if further investigation is needed and route them appropriately.
• Contact providers and other external sources for additional information.
• Adjudicate claims to meet quality and production standards.
• Release claims by deadlines to comply with company, state regulations, contractual agreements, and performance guarantees.
• Review and adhere to Policy and Procedures (P&P) for accurate and efficient claims processing, suggesting process improvements.
• Maintain a high degree of discretion and confidentiality in compliance with federal, state, and departmental guidelines.

Required Skills, Experience & Education:

• High School diploma or equivalent.
• 1-2 years of medical claims processing experience.
• 10-key proficiency of 135 wpm.
• Typing speed of a minimum of 35 wpm.
• Knowledge of medical terminology, CPT codes, and ICD-10 codes.
• Strong verbal, written, and interpersonal communication skills.
• Analytical, problem-solving, and organizational skills.
• Ability to work well under pressure.
• Ability to maintain confidentiality and project a professional business image.
• Ability to maintain balanced performance in production and quality.

Working Conditions:

• Office environment with extensive PC and keyboard work, sitting, and phone use. Must navigate multiple screens.
• Work in excess of 37.5 hours per week, including evenings and occasional weekends, may be required.

Benefits:

• Medical, Dental, Vision, Pharmacy, Life, & Disability Insurance.
• 401K with Matching.
• FSA.
• Employee Assistance Program.
• PTO and Company Paid Holidays.