Moda Health Dental Claims Fraud and Abuse Coordinator in Portland, Oregon

Dental Claims Fraud and Abuse Coordinator

Job Title

Dental Claims Fraud and Abuse Coordinator


Open Until Filled





Other Location

Job Class: P10/108.0


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.

Currently, Moda Health is seeking a Dental Claims Fraud and Abuse Coordinator. This position will investigate, track and respond to potential dental fraud and abuse cases for the dental claims department. Review, log and respond to provider correspondence.

Primary Functions:1. Process all member and provider potential fraud cases. Perform a complete review and investigation at each stage of the fraud and abuse process and ensure the appropriate documentation.2. Respond in writing to provider correspondence within 10 calendar days. Respond in a timely manner to fraud and abuse cases.3. Communicate effectively with other departments such as Customer Service, Membership Accounting, Regulatory Compliance, Dental Professional Relations, and Healthcare Services to ensure all cases are completed fully and accurately. 4 Communicate by letter and/or telephone with members, subscribers, and providers regarding claims/policies on Moda benefit plans.5. Interpret contracts and determine actions required.6. Adjust or process claims as necessary. 7. Perform total claim review to determine over/underpayment on problem claims.8. Prepare files for supervisor, consultant, president, and vice president of Moda.9. Research and respond to all provider correspondence.10. Send requests for chart notes and clinical when necessary.11. Document accurately in Facets regarding outcome of potential fraud and abuse cases and dental correspondence.12. Perform all primary functions of a dental claims support processor level II13. Other duties as assigned.

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.

Required Skills

  1. High School diploma or equivalent

  2. 1-2 years experience as a senior Claim Support Processor preferred

  3. Demonstrated knowledge of multiple benefit plans and Moda administrative policies.

  4. Demonstrated strong reading, verbal, written and interpersonal communication skills.

  5. Demonstrated initiative, analytical, problem solving and organizational skills.

  6. 10 key proficiency of 105 spm net on a computer numeric keypad.

  7. Type a minimum of 25 wpm net on a computer keyboard.

  8. Ability to work well under pressure, meet deadlines and produce a high volume of work.

  9. Ability to read and interpret contracts and apply Moda policies and procedures.

  10. Knowledge and understanding of fraud and abuse procedures.

  11. Ability to maintain confidentiality and project a professional business image.

  12. Proficiency in Moda operating systems.

  13. Ability to come into work on time and on a daily basis.

  14. Ability to communicate positively, patiently and courteously.

  15. Demonstrated proficiency in computer applications such as, Word and excel