Clinical P&R Support Spec I Job Title Clinical P&R Support Spec I Duration Open until filled Description Let’s do great things, together! About ModaFounded 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. Position SummaryThe Clinical Policy & Reimbursement Support Specialist I provides assistance and support to the Clinical Policy & Reimbursement team and Claims Manager related to clinical editing vendor. Recommend and coordinate processes to enhance and problem solve new or inconsistent claim payment and coding policies related to clinical editing. This is a FT WFH role. Pay Range$22.88 - $28.60 ​​​hourly (depending on experience) Please fill out an application on our company page, linked below, to be considered for this position. https://j.brt.mv/jb.do?reqGK=27747734&refresh=true 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 required. Bachelor’s degree preferred. + At least two years health insurance industry experience in medical claims, healthcare services, or customer service. + Understanding of principles of clinical editing and/or ability to learn & apply these concepts. Certified Professional Coder (CPC) designation desired. + Understanding of insurance industry, balance, and interaction of multiple factors (e.g., business needs, clinical issues, regulatory requirements, systems, coding principles, legal/contractual, service/satisfaction). + Ability to perform project management. + Prior experience in review of medical records would be helpful. + Proficiency with Microsoft Office applications and internet research. + Strong organizational, analytical, and problem-solving skills required. + Excellent oral and written communications. + Ability to work well under pressure in a complex and rapidly changing environment. + Ability to take initiative, self-starter, and work well within a team environment. + Maintain confidentiality and project a professional business appearance. Primary Functions: + Develop content expertise of clinical editing software which includes customization of edits, coordination of testing of new releases with Information Services and Vendors and contact with clinical editing vendors. + Develop content expertise for clinical aspects and effectiveness of clinical editing to ensure consistent and appropriate procedure code reimbursement, to maximize savings from claims incorrectly coded by providers. + Perform research related to new and updated clinical edits to make recommendations on edit acceptance. + Update Clinical Editing Decision Log with new and updated edits adopted by Moda. + Review provider and member complaints and appeals to determine trends and recommend changes for continuous improvement edits related to coding. + Communicate with vendors, providers, and internal employees through written correspondence on issues related to clinical editing. + Perform other related duties and projects as assigned. Working Conditions & Contact with Others + Office environment with extensive close PC and keyboard work and constant sitting for prolonged periods. Must be able to navigate multiple screens. Considerable interaction with others, which includes on the phone, in person, and through written correspondence. Work in excess of 37.5 hours, including occasional nights and weekends, to meet business need. + Internal with Claims, Healthcare Services, Customer Service, Benefit Configuration, Provider Relations, and external customers, including vendors, group administrators, and providers to research and resolve coding inquiries. 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. 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 via our humanresources@modahealth.com email.