Health Navigator I | JobSetuu

Description

Job Overview

• Source: RemoteOK

Job Description

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.

Job Summary

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 position requires staff to be flexible with their work schedule to meet the client’s needs. This is FT WFH role.

Pay Range

$21.30 - $23.96 hourly.

• Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.
  
  

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

https://j.brt.mv/jb.do?reqGK=27780727&refresh=true

Benefits

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

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 other 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 over the phone and in writing.
• Excellent analytical, problem solving and decision-making skills.
• 10-key proficiency of 105 kpm net on a computer numeric keypad.
• Type a minimum of 25 wpm net on computer keyboard.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Ability to maintain excellent attendance and punctuality.
• Maintain confidentiality and project a professional business presence.
• Ability to work with multiple applications across multiple monitors at once and learn new applications as needed.
• Experience using Microsoft Office products including Outlook, OneNote and Teams.
• Experience with TriZetto Facets helpful.
• Ability to learn independently and take initiative to constantly improve skills.
• Though open to both internal and external candidates, internal candidates must be Fully Meeting performance expectations in their current position. Exceeding in Accuracy and Customer Service Skills is preferred.
• Complete Effortless Experience training and certification after hire.
  
  

Primary Functions

• Applicants will handle either medical, dental or pharmacy inquiries or a combination of two of these, depending on existing skills and training. Opportunity for promotion to Health Navigator II upon learning all three lines of business.
• 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. May include use of multiple resources, contact with internal departments and multiple phone calls to providers, pharmacies and other carriers to resolve a situation completely.
• Work with internal departments via email, phone or meetings to resolve member issues and ensure clear communication of the member’s needs.
• Repeatedly analyze situations and communicate effectively in a fast-paced environment that includes working with frustrated or angry callers.
• Use the Moda 360 Navigator Console to review recommended health actions and programs, recommend programs based on personalized member data and assist members in understanding and setting up programs or completing recommended health actions.
• Use multiple resources simultaneously to research member issues. These could include Facets, Benefit Tracker, Content Manager, eviCore portal, Navitus, CoverMyMeds, Moda 360 Navigator Console and other internal and external websites depending on the line(s) of business.
• Provide complete and accurate information in a professional manner both verbally and in writing.
• Talk on the phone or respond via chat while simultaneously researching the caller’s questions and documenting the interaction.
• Apply mathematical skills to determine correct benefit and claim information and manually calculate and update dental incentive levels when needed.
• Exercise judgment, initiative, and discretion with confidential and sensitive subject matter.
• Provide thorough resolution when at all possible for members by using critical thinking skills, extending yourself and reducing effort on the part of the caller. This could include reaching out to internal and external sources (including service providers) to assist in resolving the issue for the member and making multiple follow-up calls to the member until the issue is resolved.
• Perform related duties:
• Review, update and become familiar with new and revised benefit information.
• Build and maintain proficiency in claim processing procedures to determine whether a claim was processed or adjusted correctly. Communicate reasoning to callers in language appropriate to the caller’s experience level.
• Request claim adjustments required due to processing or configuration errors or new information and determine which incorrect processing is the result of a configuration error versus a processing error. When a configuration error is encountered, communicate with leadership to have it corrected.
• Identify confusing or incomplete information in all internal and external resources, plan documents and member communications and make suggestions for improvements.
• Update and enter primary care physician selections based on plan benefits (medical only).
• Complete provider searches that may include calling several providers to locate providers who are in-network, available and meet the member’s care needs.
• Work with internal departments to help resolve member gaps in care when possible, including work with the Healthcare Services or Pharmacy teams on exceptions and authorizations for those trained in medical or pharmacy, respectively.
• Advocate on behalf of members when they encounter issues with obtaining covered care or medications from providers and/or pharmacies.
• Place overrides to allow pharmacies to dispense medication at the point of service when appropriate based on plan details and internal policies (pharmacy only).
• Address and explain complaints, appeals, and grievances.
• Provide customer service to walk-in members.
• Send emails or text messages to members to follow up on call details or provide forms, website links or other plan documents.
• Send faxes to providers to allow them to submit medication authorization requests (pharmacy only).
• Provide timely follow up and return calls when these are required.
• Answer calls within PG service level agreement.
• Complete continuing education on excellent customer service skills.
• Perform other related duties and projects as assigned by lead, supervisor or manager.
  

Contact With Others & Working Conditions

• Constant sitting and telephone use. Close PC monitor and keyboard work. Must be able to work with multiple applications open on multiple monitors and to type documentation and research while speaking with a caller. Constant interaction with others on the phone, in writing and in person. Video calls via MS Teams when required by supervisor or manager.
• Inside the company with Medical Claims, Healthcare Services, Dental Claims, Dental Provider Relations, Marketing, Group Integration, Medical Provider Relations, Pharmacy Operations, Case Management and others based on the line of business and as needed to resolve the customer’s issue. Outside the company with members, providers, attorneys, policyholders, brokers, service providers, pharmacies and other insurance carriers.
  
  

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 & Danielle Baker via our humanresources@modahealth.com email.

Expert Career Tips for Health Navigator I Roles

To succeed in a competitive market as a Health Navigator I , you need more than just technical skills. Here are some expert strategies to elevate your profile:

• Build a Strong Portfolio: For technical roles, a clean GitHub or a personal project site is essential. For non-technical roles, a case study portfolio demonstrating problem-solving and impact is equally valuable. Show, don't just tell, what you have achieved in your previous positions.
• Master the Narrative: When interviewing, use the STAR method (Situation, Task, Action, Result) to structure your answers. Quantify your results wherever possible—mentioning "increased efficiency by 20%" is much more impactful than saying "improved efficiency."
• Continuous Learning: The industry moves fast. Whether it's staying updated with the latest AI tools or mastering a new management methodology, continuous professional development is key. Consider obtaining industry-recognized certifications that align with Health Navigator I requirements.
• Networking: Connect with other professionals in similar roles. Join online communities, attend webinars, and engage in meaningful discussions on professional social networks. Often, the best opportunities come through referrals and community engagement.
• Soft Skills Matter: Communication, empathy, and leadership are often the deciding factors between two equally qualified technical candidates. Cultivate these skills as they are universally valued across all industries and seniority levels.

Additionally, research the specific company's culture and values. Tailoring your application to show how you align with their mission can significantly increase your chances of moving forward in the process.

Salary & Compensation

Salary not disclosed; typically competitive for the role.

Work Arrangement

Type: On-Site

Standard business hours at the office.

Comprehensive Application Strategy & Hiring Process

Applying for a new role is a marathon, not a sprint. Follow this strategic approach to maximize your success rate:

1. Initial Research & Tailoring

Don't send the same resume to every employer. Spend at least 30 minutes researching the company. Look for recent news, their product roadmap, and their team structure. Modify your summary and core competencies to reflect the specific keywords found in the job description.

2. The Perfect Cover Letter

If the application allows for a cover letter, use it to tell a story that your resume cannot. Explain why you are passionate about this specific company and how your unique background makes you the perfect fit for the challenges they are currently facing.

3. Navigating the Multi-Stage Interview

Most modern hiring processes involve 3-5 stages. This typically includes a recruiter screen, a technical or skill-based assessment, a peer interview, and a final leadership round. Prepare for each stage differently: focus on enthusiasm and fit for the recruiter, technical depth for the assessment, and strategic vision for the leadership round.

4. Post-Interview Follow-Up

Always send a personalized thank-you note within 24 hours of each interview. Reference a specific topic discussed during the call to demonstrate your active listening and genuine interest in the role.

By following these steps, you demonstrate a high level of professionalism and attention to detail that sets you apart from the average applicant.

Typical Interview Process

1. Resume screening
2. HR call
3. Skill interview
4. Final manager interview
5. Offer

Tip: Research the company's products and culture.

Global Market Intelligence & Relocation Insights

At JobSetuu, we specialize in helping talent navigate the global job market. Here is what you need to know about the current landscape in Global and beyond:

The demand for skilled professionals is increasingly borderless. For roles based in Global, understanding the local cost of living, visa requirements (if applicable), and cultural nuances is vital. If this is a remote role, consider the time zone alignment and the asynchronous communication culture of the hiring organization.

Relocation Support: Many forward-thinking companies offer relocation packages that include moving stipends, temporary housing, and legal assistance with work permits. When evaluating an offer, look beyond the base salary—consider the total compensation package, including equity, bonuses, and healthcare benefits.

Work-Life Balance Trends: Hybrid and remote work have become standard in many regions. Research the local labor laws and common practices regarding work hours and vacation time to ensure the role aligns with your lifestyle goals.

Leveraging JobSetuu's tools can help you compare salaries across different cities and understand the "purchasing power" of your potential offer, ensuring you make an informed decision for your long-term career path.

Skills & Competency Roadmap for Professional Development

To remain competitive in Professional Development, we recommend focusing on the following core competencies over the next 12-18 months:

• Technical Mastery: Deepen your expertise in the core tools and languages relevant to your field. For developers, this might be cloud architecture; for marketers, it might be data-driven attribution modeling.
• AI Augmentation: Learn how to leverage generative AI and automation tools to increase your productivity. Understanding how to integrate these technologies into your workflow is becoming a non-negotiable skill.
• Leadership & Strategy: Even in individual contributor roles, the ability to think strategically and lead projects from inception to completion is highly valued. Focus on stakeholder management and high-level project planning.
• Data Literacy: The ability to interpret data and use it to drive decisions is essential across all business functions. Familiarize yourself with data visualization and basic analytical concepts.

By investing in these areas, you not only prepare yourself for the role you are applying for today but also build a resilient foundation for the opportunities of tomorrow.

Apply via JobSetuu

Discover your next career milestone on JobSetuu. This Health Navigator I position is part of our commitment to bringing you the most relevant and high-impact job openings globally. At JobSetuu, we simplify your job search by aggregating premier listings and providing the tools you need to stand out. Don't miss the chance to elevate your professional journey—explore more opportunities and career insights on our platform today.