Reinsurance Specialist jobs in Clackamas, OR

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.

​​​​Please follow the link below to apply to this position:

• https://j.brt.mv/jb.do?reqGK=27709024&refresh=true

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

• PST
• Full time minimum 7.5 work days with 37.5 work weeks

Primary Functions:

1. Identify, evaluate, track and monitor reports for potential high dollar cases and provide advance notification to the reinsurer as required by the contract.
2. Effectively communicate with Healthcare Services staff regarding high dollar cases.
3. Prepare and research all reinsurance claims and submit monthly claims to the reinsurance carrier once a member has exceeded the stop loss for the current year. 
4. Maintain a high level of accuracy when reconciling high dollar claims data totals, from more than one reporting system, in a timely manner
5. Update High Dollar Report information shared by various departments throughout Moda Health, on an on-going basis.
6. Act as a liaison between Healthcare Services staff, claims, the reinsurance carrier, and broker to ensure complete and accurate information is submitted in a timely and accurate manner.
7. Develop, update, and maintain reinsurance documentation and resource materials as needed to ensure information is current and up to date.
8. Facilitate quarterly reinsurance meetings and participate in other internal work groups and committees. 
9. Attend external monthly meetings with reinsurance carriers, brokers, and insured groups to provide support, address cost containment, and coordinate carrier efforts to set reserves.
10. Receive and interpret reinsurance contract language for each line of business.  Enact and confirm Moda Health compliance with existing agreements.
11. Contribute to annual contract renewals by supplying accurate disclosure information and context on member costs to stakeholders in contract negotiations.
12. Participate in the testing, tracking, and implementation of individual high risk reinsurance pools to remain compliant with the rules for each state of operation.
13. Provide support and assist with audits, both internal and external, as necessary.
14. Review reimbursement explanations from reinsurance carriers, tracking amounts received, and triaging any pended or denied amounts in accordance with terms of the contract.
15. On-going communication with staff from Corporate Accounting and Corporate Data, providing accurate information on claims submitted for reinsurance and the claims dollars recovered.   Work reconciliations from Accounting on a quarterly basis as part of MAR controls.
16. Research and gather factual reinsurance claims issues and identify complex issues which should be referred to Supervisor and/or Manager.
17. Assist with drafting correspondence regarding reinsurance coverage and claims related issues.
18. Assist the assigned team with audit duties and responsibilities as determined by the Supervisor and/or Manager, as time permits.
19. Perform other duties as assigned

1. High school diploma or equivalent.  Degree in a health-related field preferred.
2. One to two years’ medical claim processing or customer service dealing with all types of plans/claims and consistently exceeding performance levels.
3. Knowledge and understanding of Moda Health’s contracts and administrative policies affecting claims and customer service.
4. Strong Microsoft Excel and other Microsoft Office applications.
5. Excellent reading, oral, and written communication skills, and ability to interact professionally, patiently, and courteously.
6. Good analytical, problem solving, decision making, organizational, and detail-oriented skills with ability to shift priorities. 
7. Demonstrated strong, effective, and diplomatic interpersonal skills with employees of all levels and to participate effectively as a team player.
8. Ability to work well under pressure in a complex and rapidly changing    environment.
9. Always maintain confidentiality and project a professional business presence and appearance
10. Demonstrated consistent ability to comply with company rules and policies.
11. Maintain attendance above company standards.
12. Adheres to all other company policies and procedures.

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.

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