Let’s do great things, together

Founded in Oregon in 1955, ODS, now 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.

The Quality Specialist is responsible for monitoring and maintaining compliance with state and federal regulations. This position will be responsible for gathering and conducting quality assurance audits for varying aspects of commercial appeals and grievances. This position will also analyze appeal data and develop reports following the technical specifications for reporting to accrediting and regulatory organizations, client groups, healthcare organization partners, and quality improvement committees.

This is a Remote PST position. We are only offering this position to candidates living in or willing to relocate to AK, AZ, FL, ID, OR, TX, or WA.

Follow the link below and complete an application for this position.

• https://j.brt.mv/ATS/jb.do?reqGK=27691741

Benefits:

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

Schedule:

• PST

Required Skills, Experience & Education:

• College degree or equivalent work experience.
• A minimum of 3 years’ experience in healthcare/insurance preferred, with a preference for those with experience in appeals and grievances.
• Ability to audit appeals and grievances with a high degree of accuracy, and within established timelines.
• Ability to plan, organize and prioritize task assignments to ensure established guidelines, timelines and quality goals are met.
• Project management skills. Ability to track and coordinate multiple projects and meet timelines.
• Detail oriented and proven initiative, analytical, problem solving, critical thinking and organizational abilities.
• Sound understanding of appeal utilization management, claims processing and administration workflows, ability to plan training for new appeal programs and projects, and measure compliance with state and federal requirements as well as with accreditation standards.
• Understand Medicare and Medicaid healthcare insurance dynamics and provisions.
• Working knowledge of state and federal laws governing member appeals & grievances.
• Ability to instruct, motivate, and direct individuals at various skill levels in individual and group face to face settings.
• Proficiency in Moda Health operating systems (Facets) preferred.
• Strong Microsoft Excel preferred.
• Ability to maintain confidentiality and project a professional business image.
• Ability to communicate positively, patiently, and courteously.
• Ability to come into work on time and on a daily basis.

Primary Functions:

• Interpret Technical specifications for building and executing reports on the required schedule.
• Responsible for building queries to extract data from the Facets databases and other data sources to produce ad hoc, weekly, monthly, quarterly, semi-annual, and annual reports.
• Complete monthly audit of appeal & grievance cases to ensure all aspects of the case are completed accurately
• Maintain and update the appeal and grievance case auditing tool so that it most appropriately reflects the completeness of the file documents.
• Monitor data entry of member appeals into databases and perform quality checks to ensure accuracy in grievance and appeal reports.
• Track and trend audit results. Responsible for providing specific feedback and process improvement recommendations to the Member Appeal Supervisor to increase overall quality.
• Analyze, interpret, and report appeal and grievance data to facilitate internal and external customer (state and federal entities) understanding of the reports and the impact to them.
• Evaluate medical, dental and pharmacy appeals and grievance data to identify trends and patterns, pinpoint issues and areas for improvement and recommend solutions and alternatives.
• Collaborate with the appeal supervisor to engage the appeal team or other departments in resolution of issues by taking corrective action. Monitor the effectiveness of corrective action with ongoing analysis of appeal and grievance data.
• Participate in internal meetings regarding new and current group reporting requirements as well as changes in state and federal regulations. Update reporting schedule and necessary to reflect these updates and changes.
• Ensure compliance with applicable state, federal and accrediting member appeal utilization management standards, quality assurance and quality improvement standards.
• Identify and monitor trends and/or gaps in services to improve enrollee experience, address operational issues, and advise departments/staff of corrective measures to prevent recurrences.
• Prepare for and participate in audits and reviews by external organizations, including the National Committee for Quality Assurance (NCQA), and CMS.
• Assume the lead role in developing the grievances and appeal report for the organization’s annual quality evaluation.
• Perform other duties and projects as assigned.

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.

For more information regarding accommodations please direct your questions to Kristy Nehler and Daniel McGinnis via our humanresources@modahealth.com email.