Moda Health Medicare Operations Specialist in Portland, Oregon

Medicare Operations Specialist

Job Title

Medicare Operations Specialist


Open Until Filled





Other Location

Job Class - P11/209


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 Medicare Operations Specialist. The Medicare Operations Specialist serves as the Medicare Advantage knowledge liaison to the operational departments of Customer Service, Membership Accounting, Provider Contracting, Medical Claims, Healthcare Services and Pharmacy Operations. The Medicare Operations Specialist researches complex issues and questions, provides training and initiates audits to identify and address barriers and business gaps, making recommendations for improving compliant operational outcomes. Primary Functions:1. Locates Medicare Learning Matters documents from the CMS website, as they are released; analyzes content and assigns to appropriate business unit(s) for implementation.2. Performs the Plan to Plan financial accounting and reimbursement activities for Moda’s Medicare contracts.3. Identifies potential new members; initiating marketing mailings and reaching out to Sales and Services to make specific outbound calls.4. Maintains personal knowledge of Medicare’s changing rules by reading all Health Plan Management System (HPMS) and CMS Chapter releases.5. Participates in bi-weekly CMS Part C & D User calls.6. Becomes knowledgeable in the end to end business processes of an assigned unit.7. Works with the business unit to develop and review materials the unit is using for the staff training of Medicare regulations and rules.8. Facilitates operational integrity through auditing of business unit tasks.9. Administrator of the SharePoint Medicare Work plan; assigning tasks to appropriate business areas and monitoring to completion.10. Attends business unit meetings as needed, for providing instruction or serving as resource.11. Partners with operational areas for various CMS audit preparation, assisting in the preparation of any Corrective Action Plans.12. Provides input to operational areas regarding content of their Medicare related Policies and Procedures.13. Participates in cross-departmental projects and endeavors as assigned.14. Works closely with the Medicare Compliance Officer, Medicare Operations Manager, and Medicare Products Manager to research and resolve complex issues.15. Responsible for quality and continuous improvement within the job scope.16. Perform 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. Bachelor’s degree or equivalent healthcare industry experience.

  2. Working knowledge of Medicare and the Centers of Medicare and Medicaid Services (CMS) rules. Medicare Advantage experience preferred.

  3. Demonstrated success within a rapidly changing work environment.

  4. Knowledge of CMS’s Health Plan Management System (HPMS) is desired.

  5. Ability to independently and collaboratively develop and create.

  6. Planning and organizational skills which support both individual and team goals.

  7. Ability to instruct, motivate, and direct individuals at various skill levels over the phone, face to face and in a classroom environment.

  8. Demonstrated strong, effective and diplomatic interpersonal skills working with employees of all levels.

  9. Analytical skills which identify technical needs and suggest an effective course of action.

  10. Working knowledge of WORD, EXCEL, and PowerPoint.

  11. Excellent reading, oral and written communication skills.

  12. Maintain confidentially and project a professional business image, in both face to face and telephone encounters.