Delegation & Quality Registered Nurse Coordinator

About Moda Health

Established in Oregon since 1955, Moda Health is dedicated to quality healthcare by providing outstanding coverage, compassionate community support, and comprehensive employee benefits. We promote a diverse and inclusive workplace, welcoming applicants who share these values to strengthen our organization collectively.

Position Summary

This hybrid-based role in Portland, OR involves coordinating and overseeing delegated Utilization Management (UM) functions to ensure compliance with NCQA, State, and Federal regulations. Duties include auditing delegate structures, in-depth reviews of programs, operational workflows, and denial decisions. The coordinator ensures the organization remains prepared for accreditation audits, conducts quarterly Delegation Oversight Committee meetings, and records compliance discussions.

Primary Responsibilities

• Conduct pre-delegation reviews aligned with NCQA criteria such as policy evaluations, clinical guideline comparisons, contract terms verification, workflow assessments, and pre-delegation file sampling.
• Organize site visits, set agendas, and develop audit tools to facilitate pre-delegation assessments.
• Prepare and report findings to the Medical Quality Improvement Committee.
• Perform comprehensive annual reviews including program document evaluations, delegated function reports, file audits, clinical policy updates, and submission of corrective action plans for compliance issues.
• Coordinate site visits and audits for annual file reviews, reporting results to the Medical Quality Improvement Committee.
• Take proactive initiative, independently problem solve, collaborate within teams, and fulfill other assigned duties.

Interactions

Engage internally with departments like Medical and Dental Customer Service, Professional Relations, Marketing, Claims, Actuarial, IT, and HR, and externally with accreditation bodies, healthcare providers, members, and groups.

Working Conditions

Work takes place primarily in an office environment requiring extensive computer keyboard use, prolonged sitting, frequent phone communications, and managing multiple computer screens. A reliable high-speed wired internet connection is necessary for remote or hybrid participation. The role demands comfort with virtual meetings and occasional extended hours including evenings and weekends.

Compensation and Benefits

Annual pay ranges from $71,990.85 to $89,988.57, commensurate with qualifications. Benefits include medical, dental, vision, pharmacy, life, and disability insurance, 401(k) matching, flexible spending accounts, employee assistance program, paid time off, and company holidays.

Qualifications

• Current unrestricted Registered Nurse license in Oregon.
• Background in healthcare management with strong knowledge of regulatory standards.
• Thorough understanding of NCQA criteria.
• Typing speed of at least 35 words per minute.
• Proficient skills in Microsoft Word and Excel.
• Excellent analytical, problem-solving, organizational, and detail-oriented capabilities.
• Strong verbal and interpersonal communication including handling difficult customer interactions.
• Ability to perform well under pressure and maintain punctual daily attendance.
• Professional demeanor both on the phone and in person.

Equal Opportunity

Moda Health commits to equal employment opportunities regardless of race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status, or any other protected class. This applies throughout all employment practices including recruitment, hiring, promotion, compensation, and training.

Contact for Accommodations

Questions regarding accommodations can be directed to Kristy Nehler and Danielle Baker through the humanresources@modahealth.com email.