Quality Audit Specialist I (Internal Applicants Only)

Job Title

Quality Audit Specialist I (Internal Applicants Only)

Duration

Open until filled

Description

Let’s do great things, together!

About ModaFounded 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 SummaryProvides accurate and quality audits through all Customer Service channels (online chat, Inbound/Outbound phone calls, internal/external emails and post contact surveys) for all lines of business within Moda Customer Service: Medical, Dental, Pharmacy, Benefit Help Solutions and Technical Support (specialty areas: EOCCO/OHP, Individual Membership OR/WA/AK, NCQA, Performance Guarantee Groups, Specialized, Medical Intake, Technical Support, COBRA, FSA and PERS). Monitor customer contacts by selecting call recordings, voicemails, and emails, online chat transcriptions for services provided by Customer Service Agents, Technical Support Specialists, 3rd Party Vendors, Department Leads and trainees. Ensure compliance with State (EOCCO/OHP), Federal (CMS) and internal policies are met. Provide objective feedback to maintain quality assurance on all methods of contact for all lines of business and to provide ongoing training. This is a FT WFH position. Pay Range$20.88 - $26.10 ​​​hourly*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.

https://j.brt.mv/jb.do?reqGK=27740308&refresh=trueBenefits:

• 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.

• 6 months – 2 years health insurance claims 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 and detail-oriented skills with ability to shift priorities.

• 10 key proficiency of 105 spm on a computer numeric keypad.

• Type a minimum of 25 wpm on keyboard.

• Good organizational ability that allows working under pressure, handling a variety of functions and timelines while remaining up to date on changing and new information.

• Ability to work well under pressure in a complex and rapidly changing environment.

• Ability to track and coordinate multiple projects and meet timelines.

• Knowledge and understanding of Moda Health administrative policies and procedures affecting claims and customer service.

• Understand large group and individual healthcare insurance dynamics and provisions, including funding types, benefit designs, as well as Moda Health/Delta Dental benefit administration policies.

• Ability to communicate positively, patiently, and courteously.

• Proficient in Microsoft Excel, Word and Moda operating.

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

• Ability to come into work on time and daily.

• Ability to adhere to Moda attendance and flex time policy.

• Knowledge of 1 or more customer Service-related departments, including Medical, Medical Intake, Pharmacy, Dental, Tech Support, BHS, Government Programs, NCQA, PG, OHP and EOCCO with ability to be cross trained on multiple lines.

• Communicate open and effectively with the support leadership team.

• Ability to learn how to multitask between chat, email and phone Customer Service etiquette and differences with attention and accuracy.

Primary Functions:

• Audit Customer Service contacts using the approved criteria and NCQA guidelines. Ability to identify contact which require immediate coaching, follow-up and or correction.

• Measure and evaluate individual performance with focus on customer service skills, accuracy, and documentation of each contact type: inbound and outbound calls, external and internal emails, online chat, and post contact surveys.

• Ability to conduct in-depth audits for multiple lines of business as well as focused audits for NCQA, Performance Guarantee Groups, Trainees, EOCCO/OHP.

• Handle multiple team and group assignments with different methods of contacts to audit and track daily.

• Exercise good judgment, initiative, and discretion in confidential and sensitive manners,

• Evaluate audit results to identify trends and patterns, pinpoint issues and areas for improvement and recommend solutions and alternatives.

• Identify and forward examples of high-quality calls and poor calls to leadership team.

• Transcribe calls and contacts as requested.

• Assist with external email inventory on multiple lines of business.

• Assist with post contact survey results and tracking.

• Compile, track and publish reports based on audit results and monitoring of contact types. As well as track on a weekly, monthly, and quarterly basis.

• Perform other duties as assigned.

Working Conditions & Contact with Others

• Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens. Work in excess of 37.5 hours per week, including evenings and occasional weekends, to meet business need.

• Internally with Claims, Sales and Account Services, Membership, Benefit Configuration, Information Services, Customer Service, and Provider Relations. Externally with members, providers, other insurers, and agents.

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 and Daniel McGinnis via our humanresources@modahealth.com email.#INTONLY