Medical Claims Auditor I

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.

Position Summary

Provides accurate quality assurance auditing of post-payment claims to determine correct adjudication and benefit application. Completes complex reports and provide feedback on accuracy. This is a FT WFH position.

Pay Range

$18.39 - $20.58 hourly, DOE. 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.

Benefits

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

Requirements

• High school diploma or equivalent.
• 6 months – 2 years claim processing or customer service dealing with all types of plans/claims consistently exceeding performance levels.
• Strong reading, writing, and verbal communication skills.
• Good analytical, problem solving, decision making, organizational and detail-oriented skills with ability to shift priorities.
• 10-key proficiency on a computer numeric keypad.
• Type a minimum of 25 wpm net on a numeric keyboard.
• Good organizational skills, ability to work well under pressure and ability to handle a variety of functions to meet timelines.
• Able to maintain confidentiality and project a professional business image.
• Able to start work on time and daily.
• Proficiency in Facets claims processing applications and Benefit Tracker.
• Knowledge of the reporting tool system and Employer Online Services is helpful.
• Knowledge and understanding of medical claims processing administrative policies affecting claims and customer service.
• Computer proficiency in Microsoft office applications.

Primary Functions

• Audit claims daily statistically valid sampling method, using prescriber audit criteria. Performs simple adjustments as necessary.
• Conduct in-depth claims audits on performance groups, as well as focus audits for specifically identified situations on a scheduled basis.
• Compiles and publishes reports based on the results of claim audits as well as processor productivity on a weekly, monthly, and quarterly basis.
• Run report in PBIRS to conduct audits.
• Prepares required monthly and/or quarterly reports for specific group performance guarantee, production, and accuracy results.
• Identify trends from audit results and recommend improvements to increase overall quality.
• Assists in the investigation and response to performance group inquiries.
• Other duties/tasks as assigned.

Contact with Others

• Internally with Claims, Sales & Account Services, Membership Accounting, Benefit Configuration, Information Services, Customer Service and Provider Relations.

Working Conditions

• Remote work environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens.
• Work in excess of standard work week, including evenings and occasional weekends, to meet business need.