Claims Audit Coordinator

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.

Position Summary
Facilitate and coordinate all activities associated with external and internal claims audits, including audit plans, purpose of the audit, monitoring, and reporting. Responsible for the development and maintenance of cross-departmental policies, procedures, and guidelines. This is a FT WFH role.

Pay Range
$20.88 - $26.10 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=27748845&refresh=true

Benefits:

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

Required Skills, Experience & Education:

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

Primary Functions:

• Take ownership of the claims audit organizational processes; document and communicate audit parameters, timelines and deliverables to internal and external stakeholders.
• Prepare, identify, evaluate, track, and monitor claims data reports and provide information to the appropriate vendor as required by the contract.
• Effectively communicate with management and stakeholders.
• Request and prepare all claims data reports and submit claims data to appropriate vendor.
• Works closely with audit supervisor with claims sampling and pre-audit.
• Conduct in-depth claims audits on performance groups as well as focused audits for specifically identified situations on a scheduled basis.
• Participates in interim and year end claims audit requests.
• Communicates and follows up with auditors’ requests or questions related to claim audits.
• Develop, update, and maintain policies and procedure documentation and resource materials as needed to ensure information is current and up to date.
• Facilitate and participate in other internal work groups and committees.
• Receive and interpret contract language for each line of business. Enact and confirm Moda Health and Delta Dental of Oregon compliance with existing agreements.
• On-going communication with staff from Corporate, Accounting and Corporate Data, providing accurate information on claims submitted.
• Research and gather factual claims issues and identify complex issues which should be referred to Supervisor and/or Manager.
• Assist with drafting of correspondence regarding claims audits and claims related issues.
• Assist the assigned team with audit duties and responsibilities as determined by the Supervisor and/or Manager as time permits.
• Exercise judgment, initiative, and discretion in confidential and sensitive matters.
• Assists in planning and organizing all group audits.
• Oversight of audit protocols, timelines, and procedures.
• Provide support to audit team as needed.
• Perform other duties as assigned by Director (s), Manager(s).

Working Conditions & Contact with Others:

• Internally with Accounting, Membership Accounting, Claims, Corporate, Healthcare Services, Sales and Account Services, Professional Relations, and Underwriting. Externally with Insurance divisions, audit firms, employer groups, and other related vendors.
• Work is performed seated or standing for prolonged periods. Close PC monitor and keyboard work. Constant interaction with others on the phone and in person. Work in excess of 40 hours per week, including evenings and occasional weekends, to meet business needs.

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. 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 via our humanresources@modahealth.com email.