Job Details

Policy and Compliance Registered Nurse

Moda Health, Downtown Portland

Job - Health

Close Date: 12/28/2018

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 Supervisor of Policy and Compliance in our Healthcare Services department. This position supervises 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. Ensure processes and documentation are in place and in compliance with State, Federal and NCQA requirements. Prepares reports as needed. Coordinates mock audits and related. Assures readiness for all audits.
2. Provides oversight and direction to activities to ensure compliance with NCQA, State and Federal requirements for the delegated UM function. Assists w/ implementation of OHA/CCO requirements (e.g. MDT, Transformation Plan elements, etc.)
3. Develops audit tools, performs file audits, compiles results and identifies areas for improvement.
4. 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.
5. Reviews coding discrepancies, determines appropriate payment categories (TOS codes) and coordinates changes in configuration of codes for prior auth and clinical edits.
6. Participates in the review and approval of reimbursement policies and member handbook development; coordinates w/ medical criteria policies for consistency.
7. Ensures prior auth and always not covered lists are up to date and available on the website. Manages code and instruction updates to the focus chart.
8. Organizes policies and procedures to be presented at quarterly MQIC meeting, including sending agenda items to MQIC members and preparing report for management.
9. Participates in focused Quality Improvement projects
10. 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
11. 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.

Complete details: