Let’s do great things, together!

About Moda
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 values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Please fill out an application on our company page, linked below, to be considered for this position.

Benefits:

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

Required Skills, Experience & Education:

• High school diploma or equivalent.
• Six months data entry experience.
• 10-key proficiency of 135 spm net on a computer numeric keypad.
• Typing ability of 35 wpm net.
• Proficiency with Microsoft Office applications and an understanding of basic claims processing rules.
• Strong problem solving and detail orientation skills.
• Medical terminology helpful.
• Ability to adapt to frequent changes in instructions.
• Ability to come into work on time and on a daily basis.
• Maintain confidentiality and project a professional business image.

Primary Functions:

• Accountable for accurately entering prior authorizations into multiple systems, tracking requests, and meeting timeline requirements for decisions and notifications of decisions to members according to corporate policy and government regulations.
• Responsible for the assessment and evaluation of the prior authorization request prior to higher level review: prepare, assess, evaluate, and make initial determination on the PA request with the information received using established criteria.
• Responsible for completing determined prior authorization requests within established timelines, including loading PA to PBM system, and completing member/provider notification.
• Interpret formulary coverage and solve pharmacy plan benefit issues for members of multiple Medicare and Medicaid plans.  Must be able to accurately distinguish member benefit plans and determine member eligibility.
• Determine formulary status and claim rejection reasons (e.g., PA required, non-formulary excluded, quantity limits, etc.).
• Monitor pharmacy turn-around time deadlines, track requests on log and/or pend report and take action to ensure required timelines are met.
• Fax communication forms, more information required forms (MIRF’s), and review criteria to providers.
• Determine whether additional information is needed from the requesting provider’s office, complete necessary documentation, and inform provider offices.
• Communicate prior authorization decisions and ensure appropriate feedback and follow-up with all prior authorization requests via fax, telephone, and/or email to requesting providers, members, pharmacies, and internal departments.
• Provide, schedule, and run pharmacy reports as necessary to comply with departmental requirements from the direct reporting system provided by the PBM vendor.
• Support, track, maintain, and ensure data and documentation for member appeals, grievances, and complaints are provided within necessary timelines.
• Interact with providers and provider offices via fax and/or telephone to gather complete, accurate information to adequately process a prior authorization.
• Oversee direct member reimbursement request processing by PBM.
• Respond to claim processing or prior authorization/coverage determination status inquiries.
• Be an active team player, responding to the needs of the unit as they arise.
• Perform other duties as assigned.

• Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens. Work in excess of 37.5 hours per week during peak business periods as needed to meet business need.
• Internally with peers, pharmacists, and leadership within own department, Customer Service, Healthcare Services, Marketing, and Medicare Programs.  Externally with Moda members, PBM vendor, providers, provider offices, pharmacists, and pharmacies.
  
   

Together, we can be more. We can be better.
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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. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. 

For more information regarding accommodations please direct your questions to Kristy Nehler and Daniel McGinnis via our humanresources@modahealth.com email.