Health Navigator I

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 is a full-time work-from-home role.

Location: Remote (US)

Salary: $21.30 - $23.96 hourly

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, including use of multiple resources, internal departments, and external contacts.
• Work with internal departments to resolve member issues and communicate member needs.
• Analyze situations and communicate effectively in a fast-paced environment, including working with frustrated or angry callers.
• Use the Moda 360 Navigator Console to review recommended health actions and programs, recommend programs based on member data, and assist members in understanding and setting up programs.
• Research member issues using multiple resources such as Facets, Benefit Tracker, Content Manager, eviCore portal, Navitus, CoverMyMeds, Moda 360 Navigator Console, and other websites.
• Provide complete and accurate information verbally and in writing.
• Research caller questions while on the phone or chat and document interactions.
• Apply mathematical skills to determine benefit and claim information and manually calculate dental incentive levels.
• Exercise judgment, discretion, and initiative with confidential and sensitive information.
• Provide thorough resolution for members by using critical thinking, reaching out to internal and external sources, and following up until issues are resolved.
• Review, update, and become familiar with new and revised benefit information.
• Build and maintain proficiency in claim processing procedures.
• Request claim adjustments and communicate errors or configuration issues to leadership.
• Identify confusing or incomplete information and suggest improvements.
• Update and enter primary care physician selections based on plan benefits.
• Complete provider searches and locate in-network providers.
• Work with internal departments to resolve gaps in care, including authorizations and exceptions.
• Advocate for members regarding covered care or medications.
• Place overrides for pharmacy dispensing when appropriate.
• Address and explain complaints, appeals, and grievances.
• Provide customer service to walk-in members.
• Follow up with members via email or text, and send faxes to providers for medication authorization requests.
• Provide timely follow-up and return calls.
• Answer calls within service level agreements.
• Complete continuing education on customer service skills.
• Perform other duties as assigned.

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 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.
• Excellent analytical, problem solving and decision-making skills.
• 10-key proficiency of 105 kpm net.
• Type a minimum of 25 wpm net.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Maintain excellent attendance and punctuality.
• Maintain confidentiality and project a professional presence.
• Ability to work with multiple applications across multiple monitors.
• Experience using Microsoft Office products including Outlook, OneNote and Teams.
• Experience with TriZetto Facets helpful.
• Ability to learn independently and take initiative.
• Internal candidates must meet performance expectations and preferably exceed in accuracy and customer service skills.
• Complete Effortless Experience training and certification after hire.

Benefits

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

Additional Information

• This is a full-time work-from-home role.
• Applicants should fill out an application at the provided link.
• The role involves constant sitting, telephone use, and interaction with multiple applications and monitors.
• Work involves inside and outside the company with members, providers, attorneys, policyholders, brokers, service providers, pharmacies, and other insurance carriers.