Job Description

Let's 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. Let's be better together.Position Summary
Provide supervision to Customer Service Audit Specialists. Oversee Customer Service Auditing and Quality Assurance for Medical, Dental, Pharmacy, BHS, and Customer Service Support. Create monthly planners to evaluate customer service team audits, NCQA audits, EOCCO/OHP audits and Performance Guarantee group audits. Responsible for ensuring quality customer service and documentation on all lines of business through multiple channels: emails, chats and phone calls. Organize staff, set goals, ensure resources are available as needed, coach and monitor staff to develop their skills and knowledge in auditing calls from members, providers, brokers, and others. Ensure audits are handled promptly, professionally, accurately and courteously. Evaluate reports and results to ensure goals are achieved.
This is a full-time hybrid position based in Milwaukie, Oregon.
xe2x80x8bxe2x80x8bPay Range
$69,178.56 - $86,481.89 annually
*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 positionhttps://j.brt.mv/jb.do?reqGK=27747351&refresh=true
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.
• 2-4 years quality assurance or claims/customer service experience. Medical, Pharmacy and/or Dental experience is desirable.
• Strong reading, writing and verbal communication skills.
• Possess strong interpersonal skills necessary to deal with difficult issues and people.
• Effective communication skills; capable of making presentations to customers or client audiences or professional peers and working closely with upper management.
• Strong analytical, problem solving, decision making, organizational, and detail-oriented skills.
• Computer proficiency with Microsoft Office applications.
• Must maintain confidentiality and project a professional business presence and appearance.
• Demonstrate ability to consistently organize work and time to meet deadlines and complete work on a timely basis.
• Ability to come to work on time and daily.
• Must be able to work well under the pressure of frequent interruptions, the pressure to make good decisions on problems resulting from phone calls, the pressure of rapidly shifting priorities and the pressure of questions from many sources on many subjects.
• Ability to work with Quality Management software and multiple Customer Service Applications and lines of business.
• Ability to solve problems quickly and automate processes.

Primary Functions:

• Oversee Customer Service Audit and Quality Assurance for all team and individual audits for all lines of Customer Service including calls, voicemails, chats, emails, post contact surveys and SMS text.
• Ensure performance expectations are met for NCQA Accreditations and Audits, Performance Guarantee Group Audits, Alaska Dental, OHP Dental, Post Contact Surveys and address any customer service quality performance concerns as they arise.
• Review audit appeals, adjust, uphold/deny, and educate Audit Specialists and Customer Service agents.
• Conduct calibration meetings with staff and other Customer Service teams to ensure consistency.
• Create new and update existing Policies and Procedures for internal team processes and Customer Service processes for Medical and Dental Customer Service.
• Monitor adherence, evaluating performance, training, orientation, monthly auditor stat reporting, and auditing the support and operations staff to ensure quality and consistency throughout the department.
• Act as a resource to Customer Service leadership for all lines of Customer Service and contact types, as well as other departments regarding audit questions and appeals.
• Manage inquiries/appeals on call evaluations from agents and/or supervisors.
• Must know and understand benefits, claim processing, appeals, referrals and all procedures related to claims and be able to communicate accurate information to staff and others.
• Review and analyze benefits on new groups and individual plans and communicate to staff information they will need to evaluate interactions.
• Communicate with Benefit Configuration, Membership Accounting, Professional Relations, Sales and Account Services, Privacy to clarify benefits, intent, and procedures to accurately evaluate interactions.
• Work with other departments to resolve group related issues.
• Monitor staff to ensure quality and that collateral work resulting from phone calls, emails, online chats, post contact survey and internal customer support is completed and followed up promptly and on a timely basis.
• Provide direction to staff and keep them informed of expectations and performance monthly.
• Responsible for ensuring staff members (new and seasoned) are well trained and information documented is clear and accurate.
• Personnel administration including timekeeping, performance appraisals, interviewing and hiring, counseling, etc.
• Review, analyze and develop process improvement implementation plans to ensure departmental processes are efficient. Once process improvement endeavor is implemented, evaluate and modify as is appropriate.
• Perform other duties as assigned.

xe2x80x8bxe2x80x8bxe2x80x8bxe2x80x8bWorking Conditions & Contact with Others

• Constant sitting, close PC monitor and keyboard work, constant interruptions, high volume decision making. Frequent overtime. Work more than 40 hours per week, including evenings and occasional weekends, to meet business needs.
• Internal departments such as Claims, Sales and Account Services, Membership Accounting, Benefit Configuration, Information Services, Customer Service, Privacy, Provider Relations and others as needed. External: QM/post contact survey software vendor(s), members, providers, other insurers, and agents.

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

Moda Health