Lead Medical Claims Auditor

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.

Provides backup support to Supervisor for reports, questions policy development and maintenance, and identification/implementation of process improvements. Oversees department workflow and provides assignments as needed. Assists with external audits. This is a FT WFH position.

$20.88 - $23.49 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.

Please fill out an application on our company page, linked below, to be considered for this position.

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

• High School diploma or equivalent.
• Minimum of 2 years of experience as a Claims Auditor.
• Excellent reading, verbal and written communication skills and ability to interact professionally, patiently, and courteously.
• Strong analytical, problem solving, and decision-making skills with demonstrated ability to handle and resolve complaints, correct errors, and resolve departmental issues in accordance with Moda contracts and company policies.
• 10-key proficiency of 105 wpm net on a computer numeric keypad.
• Type a minimum of 25 wpm net on a computer keyboard.
• Ability to work well under pressure in a complex and rapidly changing environment.
• Ability to maintain confidentiality and project a professional business image.
• Working knowledge of all plan types, contract and policies affecting claims and customer service.
• Proficiency in all internal claims systems and Microsoft Office applications.
• Demonstrated ability to consistently organize work and time to meet deadlines and complete work in a timely manner.
• Ability to come to work on time and daily.
• Ability to work with frequent interruptions and demonstrate professional leadership.
• Demonstrated strong, effective, and diplomatic interpersonal skills with employees of all levels, and ability to participate effectively as a team player.
• Maintain confidentiality and project a professional business presence and appearance.
• Be flexible and accepting of change.

• Provide backup and support to supervisor of unit. Includes monitoring of assignments and overtime, evaluating performance, training, communicating policy to staff, and answering questions from Claims Auditors and Reinsurance Specialists.
• Ability to analyze situations and communicate effectively in a fast-paced environment that includes a wide variety of job duties.
• Provide accurate information in a professional manner.
• Exercise judgment, initiative, and discretion in confidential and sensitive matters.
• Assists in planning, organizing, and directing the activities and workflow of the department.
• Responsible for quality and continuous improvement within the job scope.
• Answer inquiries from other departments to include:
  Customer Service, Claims, Billing & Eligibility, Accounting, and Health Care Services.
• Perform related duties:
  • Communicate concerns, issues, and ideas for improvement to Supervisor
  • Develop, document, and maintain department policies and procedures.
  • Claim adjustments and file reviews.
  • Assist with External Audits
  • Monitor and maintain unit spreadsheets.
  • Assist with Reinsurance, Auditing and Claims Processing as needed.
  • Contact physicians, dentists, hospitals, and other providers when necessary to answer questions…