Moda Health. Healthcare from your head to your toes.

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Clinical Policy & Compliance Specialist
Job Title
Clinical Policy & Compliance Specialist
Open until Filled
Portland,  OR 97204
Other Location
Job Class: 215.0

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 Health is seeking a Policy and Compliance Registered Nurse in our Healthcare Services department. This position reviews compliance related to State, Federal, and NCQA accreditation, including corrective action plans; develops and updates Medical Criteria and leads cross functional committee; ensures integration of efforts across all Healthcare Services units and with internal stakeholders and business partners.

Primary Functions:

  1. Provides oversight and direction to activities to ensure compliance with NCQA, State and Federal requirements for the delegated UM function.  Consults with medical director and other physician consultants regarding policies and procedures and medical criteria.  Investigates the need for new medical criteria and develops policies as needed.  Facilitates preparation of cost analyses and makes recommendations for coverage changes. 
  2. Reviews coding discrepancies, determines appropriate payment categories and coordinates changes in configuration of codes for prior authorization and clinical edits. 
  3. Participates in the review and approval of reimbursement policies and member handbook development; coordinates w/ medical criteria policies for consistency.
  4. Participates in focused Quality Improvement projects
  5. Identifies and utilizes all appropriate clinical resources and information, including new technology, standards of care, and community resources as part of the development of medical criteria and policies and procedures
  6. Performs other duties as assigned.

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. Graduate of accredited school of nursing with unrestricted license, or bachelor’s degree in Health Services Administration or Public Health.
2. Working knowledge and a solid understanding of accreditation standards and State and Federal insurance legislation.
3. Coding certification and/or experience preferred
4. Strong verbal, written and interpersonal communication skills.
5. Proficiency with Microsoft Office applications; type a minimum of 35 wpm on the computer keyboard.
6. Analytical, problem solving, memory retention, organizational and detail oriented.
7. Ability to present in a formal group setting and facilitate group meetings.
8. Ability to work well under pressure with frequent interruptions.
9. Ability to come to work on time and on a daily basis.
10. Project a professional business image telephonically and in person.