Medical Claims Auditor I

Moda Health; Portland (OR); Remote; USD 25,000 - 28,000; Full time

Benefits offered by this job

Medical, Dental, Vision, Pharmacy,Life

401K- Matching

FSA

EAP

PTO and Holidays

Job summary

Moda Health is seeking a detail-oriented QA auditor to ensure correct adjudication and application of post-payment claims. The role supports remote operations, requiring strong analytical and communication skills.

You will generate reports and help improve accuracy and efficiency across claim processes. The ideal candidate has experience with claims processing systems and can manage multiple tasks under deadlines while maintaining confidentiality.

Qualifications

• High school diploma or equivalent.
• 6 months–2 years claim processing or customer service dealing with all types of plans/claims.
• Strong reading, writing, and verbal communication skills.
• Good analytical, problem solving, organizational and detail-oriented skills.
• 10-key proficiency on a computer numeric keypad.
• Type a minimum of 25 wpm net on a numeric keyboard.
• Ability to maintain confidentiality and project a professional business image.

Responsibilities

• Audit claims daily using prescriber audit criteria and perform simple adjustments as needed.
• Conduct in-depth audits on performance groups and focused audits on identified situations.
• Compile and publish weekly, monthly, and quarterly audit reports and processor productivity.
• Run PBIRS reports to conduct audits and ensure accuracy.
• Prepare monthly/quarterly reports for group performance guarantees and results.
• Identify trends from audits and recommend improvements to raise overall quality.
• Assist in investigations and respond to inquiries from performance groups.
• Other duties as assigned.

Skills

Reading & writing

Verbal communication

10-key data entry

Typing 25 wpm

Claims processing systems

Microsoft Office

Confidentiality

Education

High school diploma

Tools

Facets

Benefit Tracker

Employer Online Services

PBIRS

Job description

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

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.
• Ability to maintain confidentiality and project a professional business image.
• Ability 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.

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.

For more information regarding accommodations please direct your questions to Kristy Nehler & Danielle Baker via our [e-mail] email.