**Medical Mutual employees must submit their applications through MySource.Note: This is a hybrid role requiring 4 days per week on-site in our Brooklyn, Ohio office. Seeking applicants that reside within a 50-mile radius of the Brooklyn, Ohio office.Provides strategic and operational leadership for the Clinical Review & Recovery program within Payment Integrity. Manages Itemized Bill Reviews (IBRs), DRG validation, clinical coding audits, payment policy application, and post payment clinical claim reviews to ensure accurate reimbursement, regulatory compliance, and optimal recovery outcomes. Evaluates review results and policy effectiveness to drive continuous improvement, operational efficiency, and cost savings. Collaborates with internal partners and external vendors to align clinical review operations with evolving reimbursement models, regulatory requirements, and future-state strategy.
Responsibilities:- Manages the review and analyses of clinical coding and medical policies and procedures and the impact to claim payments.
- Provides leadership and oversight for the Clinical Review & Recovery teams to strengthen the effectiveness of the clinical coding and claims payment auditing program and provides clinical coding and clinical review expertise for the Medical Policy and Clinical teams.
- Monitors and analyzes department specific data reports, outcomes, and resource utilization, and leads the technical roadmap to refine business processes and optimize cost savings.
- Creates audit programs that identify issues with medical spending. Recommends and implements cost saving methodologies.
- Manages vendor relationships specific to clinical coding and claims payment audits, ensuring adherence to contractual limits, validating alignment between vendor deliverables and internal MMO activities to avoid duplication, and assessing cost effectiveness to ensure maximum value from vendor services.
- Creates and maintains policies and procedures to be followed in all clinical coding and claims payment audits by both internal staff and recovery vendors.
- Monitors production data to stay abreast of trends and alters the direction of audits accordingly.
- Performs other duties as assigned.
Qualifications:Education and Experience- Bachelor's Degree in Nursing, Healthcare Administration or similar field.
- 8 years progressive experience in health insurance operations, 3 years which are in a supervisory or project management capacity.
- 3 years of experience in clinical coding and claims payment auditing.
Professional Certification(s):- Registered Nurse with current license required.
- Certified Professional Coder (CPC) or similar designation preferred.
- Certified Professional Medical Auditor (CPMA) preferred.
- Registered Health Information Administrator/Technologist (RHIA/RHIT) preferred.
Technical Skills and Knowledge:- Comprehensive knowledge of all facets of claims, medical procedures, terminology and payment analysis and the ability to apply concepts to claim payment processes and auditing programs.
- Strong Microsoft Office and health insurance operations systems skills.
- Strong vendor management skills.
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
A Great Place to Work:
- We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
- Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
- On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
- Discounts at many places in and around town, just for being a Medical Mutual team member.
- The opportunity to earn cash rewards for shopping with our customers.
- Business casual attire, including jeans.
Excellent Benefits and Compensation:
- Employee bonus program.
- 401(k) with company match up to 4% and an additional company contribution.
- Health Savings Account with a company matching contribution.
- Excellent medical, dental, vision, life and disability insurance - insurance is what we do best, and we make affordable coverage for our team a priority.
- Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
- Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
- After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.
An Investment in You:
- Career development programs and classes.
- Mentoring and coaching to help you advance in your career.
- Tuition reimbursement up to $5,250 per year, the IRS maximum.
- Diverse, inclusive and welcoming culture with Business Resource Groups.
