Quality Assurance Auditor

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
The Government Programs Quality Assurance Auditor monitors and maintains compliance with state and federal regulations. This role conducts pre-closure audits for Medicare and Medicaid appeals and grievances, tracks department performance, and ensures procedures are followed, appeals are effectuated appropriately, and reporting is accurate. This position also supports staff training and continuous process improvement. This is a FT WFH position. 

Pay Range
$23.34 - $26.26 hourly (depending on experience)
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.

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

Required Skills, Experience & Education:

1. High School diploma or equivalent. 
   
2. 2+ years of experience as Appeal Coordinator or related experience. 
   
3. Advanced knowledge of benefit plans and Moda Health administrative policies, products, and business lines, including CMS Medicare and Medicaid rules. 
   
4. Strong reading, verbal, written, and interpersonal communication skills. 
   
5. Demonstrated analytical, problem-solving, and organizational skills. 
   
6. 10 key proficiency of 105 kspm 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 and meet deadlines. 
   
9. Proficiency with Microsoft applications such as Word, Excel, or other core operating systems. 
   
10. Advanced knowledge of complaint and appeal procedures. 
    
11. Strong attention to detail, with a strong focus on quality.
    
12. Ability to maintain confidentiality and project a professional business image. 
    
13. Ability to meet attendance policies and work schedule, including occasional overtime, weekend, and holiday coverage. 
    
14. Aptitude for communicating positively, patiently, and courteously. 
    
15. Ability to maintain large workload and meet short turnaround times.
    

Primary Functions :

1. Complete pre-closure audits of appeal and grievance cases to ensure accuracy and completeness.
2. Communicate with staff and other departments to ensure complete and fair reviews of grievances, complaints, and appeals.
3. Provide clear, actionable feedback to Appeal Coordinators to improve quality and development.
4. Monitor data entry for appeals and grievances and perform quality checks on reporting.
5. Track and trend audit results and provide recommendations to improve quality and efficiency.
   
6. Partner with leadership to create and implement initiatives that improve compliance and performance.
   
7. Review contracts and supporting documentation to determine appropriate actions. 
   
8. Support staff in meeting accuracy and quality standards for case completion. 
   
9. Participate in meetings regarding reporting requirements and regulatory changes.
   
10. Maintain and update audit tools to align with documentation and reporting requirements. 
    
11. Assist with standard verbiage for routine grievances and complaints.
    
12. Ensure compliance with state, federal, and plan partner guidelines for member appeal utilization management standards, quality assurance, and quality improvement standards.
    
13. Serve as a subject matter expert on Medicare and Medicaid appeals and grievances.
    
14. Handle and interpret complex appeals and grievances.
    
15. Other duties as assigned.
    

Working Conditions:

• Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need.
• Internally with Medicare Programs, Medicaid Services, Professional Relations and Contracting, Customer Service, Membership Accounting, Claims, Legal Services, Regulatory, Compliance, Privacy and Healthcare Services teams. Externally with Members, Provider Offices, Independent Review Entities, Attorneys, Coordinated Care Organizations, the Oregon Health Authority and contracted vendors.

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.