Milwaukie - OR Full Time 2 months ago

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.

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.

We are currently seeking a Customer Service Representative for our Pharmacy Customer Service Department. This position is responsible for providing customer service to members of multiple benefit plans by analyzing the caller’s needs and by providing timely and accurate responses. Answer calls from members (Commercial Medicare Part D and UMP/Aetna), agents, providers, hospitals, pharmacists, PBM and Mail Order carriers regarding pharmacy benefits or other issues. One year customer service experience is ideal but remote training will be offered. High School diploma or equivalent required, proficient computer skills, typing and 10-key required.

This position can be based in Alaska, Arizona, Idaho, Oregon, Texas, and Washington.
Training Start date: August 1st, 2022

Primary Functions:
01. Primary Pharmacy phone coverage answering 30+ calls a day and handle to resolution. Answer claim benefit questions from callers on both group and individual pharmacy products. Provide solutions to problems, confirm eligibility, explain benefits and/or plan coverage.
02. Applies mathematical skills to provide and determine correct benefit information.
03. Performs related duties:
a. Reviews, updates and become familiar with new and revised benefit information, drug information or claim processing procedures.
b. Be familiar with drug names and recognize new drugs as they are released and added to the ODS drug list.
c. Request claim adjustments required because of error or new information. May process adjustments.
d. Resolve and record complaints, coverage determinations, appeals, and inquiries.
e. Provide customer service to walk-in members when necessary.
f. Contacts physicians, pharmacies and PBM’s when necessary to answer questions and obtain or provide information.
g. Provide timely follow up and return calls when these are required.
h. Answer calls within service level time.
04. Ability to meet all CMS guidelines/deadlines as it pertains to Pharmacy benefits management.
05. Performs special projects as assigned by Supervisor.
06. Ability to write procedures documentation in the UPM format as assigned by Supervisor.
07. Performs special projects as assigned by Supervisor.

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.

01. High School diploma or equivalent. 02. 1 – 2 years experience in a pharmacy or insurance setting helpful. 03. Practical knowledge of medical terminology desired. 04. Knowledge of diagnosis and procedure coding desired. 05. Claim processing experience or prior customer service experience or other related experience such as pharmacy clerk or technician. 06. Excellent verbal and written communication skills and ability to interact professionally, patiently, and courteously with customers over the phone and in person. 07. Good analytical, problem solving and decision-making skills. 08. Type a minimum of 25 wpm net on computer keyboard. 09. Must be proficient with Microsoft Office applications, and able to learn MedAccess, Business Objects, CF, GF, EOS and ITS. 10. Ability to work well under pressure with frequent interruptions and shifting priorities. 11. Ability to come to work on time and be ready to work at the time of assigned shift. 12. Maintain confidentiality and project a professional business presence and appearance. 13. Knowledge of ODS business processes and how they relate to the Pharmacy area helpful. 14. Demonstrated ability to comply with company rules and policies. 15. Demonstrated ability to handle difficult, angry calls and benefit issues with little assistance. 16. Ability to come in to work on time and on a daily basis.

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