Pharmacy Customer Service Representative

About Moda Health

Moda Health, established in Oregon in 1955, prides itself on a commitment to quality healthcare. The company focuses on delivering excellent coverage to members, supporting the community with compassion, and providing extensive benefits to its workforce. Moda emphasizes diversity and inclusion across all business areas and encourages applicants who share this dedication.

Position Overview

The Pharmacy Customer Service Representative I supports members from various benefit plans by assessing their needs and delivering timely, precise responses. The role involves using several systems to handle inquiries from members, agents, providers, hospitals, pharmacists, PBM, and Mail Order carriers about pharmacy benefits, eligibility, claims, and other related concerns. This role is a full-time remote position with Moda Health.

Key Responsibilities

• Handle member inquiries via phone, virtual meetings, or in-person regarding claims and pharmacy benefits for group and individual plans.
• Analyze situations repeatedly to provide accurate information promptly, including managing escalated and sensitive calls professionally.
• Use mathematical skills to verify and interpret benefit details correctly.
• Stay updated on benefit details, claim procedures, regulations, and new drug releases related to Moda's drug list.
• Initiate claim adjustments due to errors or new information when needed.
• Document and address complaints, appeals, and inquiries efficiently.
• Communicate with physicians, pharmacies, and PBMs to clarify information or resolve issues.
• Serve a diverse population across varying age groups with cultural sensitivity.
• Ensure timely follow-ups and return communications as required.
• Maintain departmental standards for customer interactions.
• Participate in ongoing training and collaboration with supervisors andexperienced staff.
• Coordinate with leadership and other departments to address complex or escalated issues.
• Adhere to agreed work schedules and shifts consistently.
• Complete additional duties as assigned.

Required Qualifications

• High school diploma or equivalent experience.
• One to two years of experience in a fast-paced customer service environment; experience in pharmacy or insurance is preferred.
• Keyboard typing speed of at least 25 words per minute.
• Strong mathematical ability for interpreting benefit information.
• Proficiency in Microsoft Office Suite including Word, Excel, and Outlook.
• Excellent verbal, written, and interpersonal communication abilities.
• Ability to engage thoughtfully and respectfully with culturally and linguistically diverse populations.
• Capacity to work effectively under pressure, adapt swiftly to shifting priorities, and manage interruptions.
• Ability to work independently and collaboratively as part of a team.
• Reliable attendance and punctuality.
• Maintain confidentiality and uphold a professional image.
• Meet or exceed departmental performance standards and deadlines.
• Capable of multitasking and utilizing multiple computer programs simultaneously (approximately 7–8 software platforms).

Working Conditions and Interactions

• Standard office environment involving prolonged computer use, sitting, and frequent telephone communication.
• Must have dependable, high-speed wired internet for remote work and be comfortable appearing on camera for virtual meetings and trainings.
• Work hours may exceed standard schedules including evenings and occasional weekends to fulfill business needs.
• Collaborate internally with Claims, Marketing, Billing, Eligibility, Sales, Healthcare Services, and Provider Relations teams.
• Externally engage with members, providers, attorneys, brokers, government officials, PBMs, and other insurers.

Equal Opportunity Employer Statement

Moda Health provides equal employment opportunities regardless of race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status, or any protected status. This applies to all employment aspects such as recruiting, hiring, promotion, compensation, and training.

Additional Information

For accommodation inquiries, contact the HR team via email at [email protected].

Compensation

Pay ranges from $18.39 to $20.58 per hour depending on experience and qualifications. Candidates not meeting minimum qualifications will be eligible only for the lower end of the pay scale.