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Medicaid Compliance Program Manager- Hybrid (OR & WA)

Moda, Inc - Portland, OR

Let’s do great things, together

Founded in Oregon in 1955, ODS, now 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.

Facilitates organizational compliance with state and federal Medicaid regulations, internal processes and Coordinated Care Organization partners.  The Program Manager will contribute to Moda’s Medicaid compliance program by researching and analyzing applicable laws, rules, regulations, and guidance, assisting business areas, conducting subcontractor oversight, coordinating cross departmental contractual deliverables and will assist in completing all OHA and CCO partner audits and reviews.  This position’s responsibilities are inclusive of Eastern Oregon Coordinated Care Organization (EOCCO), The OHSU IDS and ODS Community Dental.

This Hybrid PST position is open to candidates living or willing to relocate to OR or WA. 

Follow the link below and complete an application for this position.



\tMedical, Dental, Vision, Pharmacy, Life, & Disability
\t401K- Matching
\tEmployee Assistance Program
\tPTO and Company Paid Holidays




\tBachelor’s Degree or equivalent, with at least 5 years of experience in the health insurance industry required, including at least two years of experience in regulatory compliance, Oregon Medicaid compliance experience preferred.
\tAbility to work and think independently in researching, analyzing, interpreting, and disseminating information about complex administrative rule and contracts.
\tAbility to identify areas of compliance concern and develop recommendations for resolving compliance issues.
\tAbility to advise and direct all departments, including senior/executive positions, on the interpretation and implementation of regulatory requirements and contracts.
\tAbility to organize and prioritize large workloads in an efficient and timely manner.
\tDetail oriented with good organizational and problem-solving skills.
\tStrong verbal and written communication skills.
\tComputer proficiency with Microsoft Office applications, Adobe Acrobat, and Internet research.
\tMaintain a daily work schedule consistent with department attendance and work hour requirements and function in an exempt role.
\tMaintain confidentiality and project a professional business image.
\tStrong audit skills to provide regulatory feedback on any subject matter from internal departments.

Primary Functions:

\tFunction as liaison with the various departments within the organization regarding compliance with state and federal Medicaid regulations, including implementation of OHA contract changes and process/procedure changes.
\tEvaluate and interpret contract benefits based on applicable laws and internal standards and policies.
\tProvide in-depth review, interpretation, and dissemination of information regarding state and federal Medicaid regulations.
\tRespond to daily questions within the organization regarding Medicaid regulations and internal policies and procedures.
\tParticipate in all aspects of OHA external quality review activities including Compliance Monitoring Review, Mental Health Parity Review and Encounter Data Validation.
\tCoordinate and provide oversight of completion of audits and other compliance activity requests from CCO partners.
\tManage robust auditing and monitoring program of internal departments as well as subcontractors and delegates for contract and regulatory compliance.
\tWork with internal departments and subcontractors to ensure identified deficiencies are corrected in a timely manner.
\tLead completion and submission of complex, cross-departmental contractual deliverables.  Examples include, but not are limited to, Annual and Quarterly Fraud, Waste and Abuse deliverables, Quarterly Grievance and Appeal Reports and Annual Subcontractor Performance Reports.
\tDevelop and present educational materials as necessary regarding changes to Medicaid regulations, contracts and guidance.
\tMust be confident and politically attuned to build partnerships and encourage collaboration between individuals and teams.
\tRepresent the Medicaid compliance team with internal workgroups, external workgroups, OHA and CCO stakeholders and Boards of Directors as appropriate.
\tPerform other duties as assigned.

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.

For more information regarding accommodations please direct your questions to Kristy Nehler and Daniel McGinnis via our email.

72 days 3 hours ago

Moda, Inc

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Location: Portland, OR