Membership Acct Qual Analyst

Moda Health; Portland (OR); Hybrid; USD 66,878,000 - 75,246,000; Full time

Benefits offered by this job

Medical, Dental, Vision, Pharmacy,Life

401K Matching

FSA

Employee Assistance Program

PTO and Holidays

Job summary

Moda Health seeks a Quality Assurance Auditor in Portland, Oregon for a full‑time hybrid role. You will audit enrollments, billing and reconciliation daily using statistically valid sampling, report on quality trends, and ensure adherence to all applicable regulations and standards.

The ideal candidate has 1–2 years of quality review experience in a health insurance environment, strong communication and analytical skills, and proficiency with Word and Excel.

Qualifications

• High School diploma or equivalent required.
• 1–2 years quality review experience in health insurance environment preferred.
• Strong interpersonal, effective and diplomatic communication.
• Proficiency with Word, Excel and web-based tools.
• Excellent reading, verbal and written communication.

Responsibilities

• Audit enrollments, billings and reconciliation daily using sampling.
• Ensure QA standards and compliance with state and federal regulations.
• Conduct in-depth enrollment, billing and reconciliation audits.
• Prepare monthly/quarterly performance reports.
• Identify trends and recommend quality improvements.
• Create and update documentation and procedures.
• Support quality initiatives and teamwork.
• Other duties as assigned.

Skills

Interpersonal skills

Communication skills

Detail-oriented

Analytical thinking

Team player

Education

High School diploma

Tools

Microsoft Word

Microsoft Excel

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. Lets be better together.

Lets do great things, together

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. Lets be better together.

Position Summary

This is a full-time hybrid role based in Portland, Oregon. Provide accurate quality assurance auditing of pre and post enrollment, billing and reconciliation functions as performed by Membership Accounting specialists of all levels. Track and report on quality trending as it relates to specific specialists as well as department level production.

Pay Range

$23.34 - $26.26 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

Required Skills, Experience, & Education

• High School diploma or equivalent required.


• 1-2 years quality review experience in a health insurance environment, preferably in a Membership Accounting (enrollment, billing & reconciliation) department preferred.


• Demonstrate strong, effective, and diplomatic interpersonal skills with employees of all levels and participate effectively as a team player.


• Knowledge of Word, Excel, and ability to navigate web-based programs.


• Excellent reading, verbal, and written communication skills, and the ability to interact professionally, patiently, and courteously with others.


• Good analytical, problem solving, decision making and organizational, and detail-oriented skills with ability to shift priorities.


• Ability to come in to work on time and on a daily basis. Maintain attendance above company standards.


• Maintain confidentiality and project a professional business presence and appearance.

Primary Functions

• Audit enrollments, billings and reconciliation daily using statistically valid sampling methodology, using prescribed audit criteria. Performs simple adjustments as necessary.


• Ensures departmental quality assurance standards, employer group Statement of Work, and State and Federal Regulations are adhered to through auditing all Membership Accounting Specialist duties.


• Conduct in-depth enrollment, billing, and reconciliation on performance groups, as well as focused audits for specifically identified situations or specialists on a scheduled basis.


• Prepares required monthly and/or quarterly reports for specific group performance guarantees, production, and accuracy results.


• Identify trends from audit results and recommend improvements to increase overall quality.


• Creates and updates documentation, department procedures, and resource materials as needed.


• Responsible for quality and continuous improvement within job scope.


• Contributes to and supports the company's quality initiatives by encouraging team and individual contributions toward the company's quality improvement efforts.


• Fosters and atmosphere of team spirit and portrays an outgoing and positive attitude with peers, Moda and BHS Leadership, Customers, trainees, and Specialists.


• Responsible for regularly scheduled operational audits of staff members for your respective team and product line.


• Other duties as assigned.

Working Conditions & Contact With Others

• Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need.


• Internally with Membership Accounting Leadership Team, Sales and Account Services, Customer Service, Business Implementation Unit (BIU), Accounting, IS, and Medicare Operations. Externally with Clients and Customers.

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.