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Moda Health Medical Claims Auditor in Portland, Oregon

Medical Claims Auditor

Job Title

Medical Claims Auditor


Open Until Filled





Other Location

Job Class: 106.0


Let’s do great things, together

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.

Moda Health is seeking a Medical Claims Auditor. This position will provide accurate quality assurance auditing of post-payment claims to determine correct adjudication and benefit application; complete complex reports and provide feedback on accuracy.

Primary Functions:1. Audits claims on a daily basis using statistically valid sampling method, using prescribed audit criteria. Performs simple adjustments as necessary.2. Conducts in-depth claim audits on performance groups, as well as focus audits for specifically identified situations on a scheduled basis.3. Compiles and publishes reports based on the results of claim audits as well as processor productivity on a weekly, monthly, and quarterly basis.4. Runs reports in Business Objects to conduct audits.5. Prepares required monthly and/or quarterly reports for specific group performance guarantee, production and accuracy results.6. Identifies trends from audit results and recommend improvements to increase overall quality.7. Assists in the investigation and response to Market Conduct Examination inquiries.8. Performs other duties and responsibilities as assigned by management.

Are you ready to be a betterist?

If you’re ready to make a difference that matters, we want to hear from you. Because it’s time to discover what’s possible.

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.

Required Skills

  1. High School diploma or equivalent.

  2. 6 months - 2 years medical claim processing or customer service dealing with all types of plans/claims consistently exceeding performance levels.

  3. Strong reading, writing and verbal communication skills.

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

  5. 10-key proficiency of 105 wpm net on a computer numeric keypad.

  6. Type a minimum of 25 wpm net on a computer keyboard.

  7. Good organizational ability to work under pressure to handle variety of functions and meet timelines.

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

  9. Ability to come into work on time and on a daily basis.

  10. Proficiency in Facets claims processing applications and Benefit Tracker.

  11. Knowledge of Business Objects.

  12. Knowledge and understanding of Moda administrative policies affecting claims and customer service.

  13. Computer proficiency in Microsoft office applications.