Medical Claims Auditor I

Moda Health•Milwaukie, OR

4d•Remote

About The Position

Provides accurate quality assurance auditing of post-payment claims to determine correct adjudication and benefit application. Completes complex reports and provides feedback on accuracy. This is a full-time work-from-home position. The pay range is $18.39–$20.58 per hour, depending on qualifications; applicants who do not exceed the minimum qualifications are eligible only for the low end of the range. Moda was founded in Oregon in 1955 and describes itself as committed to quality, outstanding member coverage, community support, comprehensive employee benefits, and diversity and inclusion. The position works with internal teams across Claims, Sales & Account Services, Membership Accounting, Benefit Configuration, Information Services, Customer Service, and Provider Relations. The work is performed remotely and involves extensive close computer and keyboard work, constant sitting, and phone work. The employee must navigate multiple screens and may need to work beyond the standard workweek, including evenings and occasional weekends, to meet business needs.

Requirements

High school diploma or equivalent.
6 months to 2 years of claim processing or customer service experience dealing with all types of plans and claims, consistently exceeding performance levels.
Strong reading, writing, and verbal communication skills.
Analytical, problem-solving, decision-making, organizational, and detail-oriented skills, including the ability to shift priorities.
10-key proficiency on a computer numeric keypad.
Typing speed of at least 25 net words per minute on a numeric keyboard.
Ability to work well under pressure, handle varied functions, and meet timelines.
Ability to maintain confidentiality and project a professional business image.
Ability to start work on time daily.
Knowledge and understanding of medical claims processing administrative policies affecting claims and customer service.
Computer proficiency in Microsoft Office applications.

Nice To Haves

Proficiency in Facets claims processing applications and Benefit Tracker.
Knowledge of the reporting tool system and Employer Online Services.

Responsibilities

Audit claims daily using a statistically valid sampling method and prescriber audit criteria.
Perform simple claim adjustments as necessary.
Conduct in-depth claims audits on performance groups and scheduled focus audits for specifically identified situations.
Compile and publish reports on claim audit results and processor productivity weekly, monthly, and quarterly.
Run reports in PBIRS to conduct audits.
Prepare required monthly and/or quarterly reports on specific group performance guarantees, production, and accuracy results.
Identify trends in audit results and recommend improvements to increase overall quality.
Assist with investigation of and responses to performance group inquiries.
Perform other duties and tasks as assigned.