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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
Evaluates, authorizes, and manages behavioral health services to plan members. Interacts with members, family, and care providers to coordinate quality care in clinically appropriate settings. Applies clinical expertise with knowledge of resources and coverage, to promote effective, efficient treatment outcomes.

This is a FT WFH role.

Pay Range

$71,990.85 - $89,988.57 annually. This role may be classified as hourly (non-exempt) depending on the applicant's location. 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=27775722&refresh=true

Benefits:

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education:

1. Active Oregon license as a behavioral health practitioner.
2. At least three years recent experience in behavioral health (mental health and/or chemical dependency) clinical settings.
3. Excellent communication skills, both written and verbal, including ability to de-escalate and calm upset or distressed individuals.
4. Excellent analytic, problem solving, and personal time/task management skills.
5. Excellent memory retention and attention to detail.
6. Demonstrated ability to work well under pressure.
7. Ability to present oneself in a professional manner telephonically and in person.
8. Demonstrated ability to work across multiple computer applications.
9. Type a minimum of 35 wpm on a computer keyboard.
10. Ability to come in to work on time and daily.
11. Maintain confidentiality and protect the privacy of member information.

Primary Functions:

1. Promotes positive treatment outcomes by helping members identify clinically appropriate services and making referrals for Behavioral Health Case Management.
2. Assists members in navigating treatment options, understanding the authorization process, and accessing services.
3. Evaluates treatment services for medical necessity and appropriate type of treatment and level of care.
4. Provides courteous and accurate customer service to members, family members and care providers.
5. Participates in researching articles outlining evidence-based practices for behavioral health treatment and participates in revising and developing Moda Behavioral Health medical necessity criteria.
6. Participates in Inter-Rater Reliability exercises with clinical team.
7. Provides clinical consultation to Health Coaches and Nurses within Healthcare Services.
8. Tracks and reports cost-savings obtained through medical necessity denials, negotiated discounts, reduced levels of care and lengths of stay.
9. Completes Continuity of Care, Transition of Care, and Single Case Agreements.
10. Negotiates pricing for Single Case Agreements with out-of-network facilities and providers when approved by the Moda Health Medical Director and allowed by member’s plan
11. Prepares cases in a clear and concise manner for Moda Health Medical Director review.
12. Writes clear, individualized denial letters that reference specific criteria or handbook language.
13. Completes provider searches for members, family members and Moda Healthcare Service teams.
14. Understands and follows Moda authorization and utilization review processes.
15. Ensures authorization determinations meet timeliness standards and are completed promptly and accurately.
16. Communicates clearly and assertively with providers and develops and maintains positive relationships with them.
17. Completes documentation of contact with members and providers in a thorough, accurate and professional manner.
18. Reports suspected fraud, waste, and abuse to Moda Health Special Investigation Unit.
19. Uses Moda systems (Benefit Tracker, Care Web, Content Manager, Facets) to give accurate information to members and providers.
20. Resolves member and provider concerns before they become grievances/complaints, whenever possible.
21. Works in a collaborative manner with providers and other Moda employees.
22. Responds to occasional crisis calls from members. Assesses for safety, develops safety plans if needed, and provides treatment options.
23. Perform other duties as assigned

Working Conditions & Contact with Others

• Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Extensive telephone work. Occasional driving for meetings outside the office Must be able to navigate multiple screens. Work in excess of 40 hours per week, including evenings and occasional weekends, to meet business need.

• Internally with all departments. Externally with database vendor support, members, professional facilities, providers, and office staff.

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 & Danielle Baker via our humanresources@modahealth.com email.