Medical Mutual employees must submit their applications through MySource.This is a hybrid-remote role based out of the Brooklyn, OH office, with employees expected to work onsite on designated in-office days each week. Job Summary:Ensures timely, accurate, and clinically appropriate authorization determinations while maintaining full compliance with federal, state, accreditation, and internal regulatory requirements. Oversees daily PA operations, compliance monitoring, audit readiness, corrective action planning, and workflow alignment across Clinical Quality Health Services. Partners closely with UM, CM, Quality, IT, and external vendors to ensure high quality, efficient, and compliant clinical operations.
Responsibilities:- Manages daily prior authorization and clinical compliance operations, including workload distribution, productivity, quality, and service performance.
- Provides coaching, mentoring, and competency development for PA reviewers and clinical compliance staff.
- Prepares operational and compliance reports for leadership, committees, and regulatory bodies.
- Oversees policy and workflow adherence, performance management, hiring, training, and evaluation of assigned staff.
- Ensures timely, accurate, and compliant determinations using InterQual, MCG, and CMP criteria and benefit guidelines.
- Manages escalations, complex cases, and high impact determinations.
- Partners with UM, CM, Quality, IT, Provider Relations, and external vendors to maintain compliant and efficient operations.
- Supports implementation of new systems, workflows, and process improvements that strengthen operational effectiveness and regulatory compliance.
- Monitors operational and compliance KPIs and report trends to leadership.
- Fosters a culture of accountability, transparency, and continuous improvement.
- Evaluates individual and team performance to ensure departmental and organizational goals related to utilization, cost, quality, and productivity are met.
- Performs other duties as assigned.
Qualifications:Education and Experience:- Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor of Science in Nursing preferred.
- 8+ years of experience in Utilization Management, Prior Authorization, Clinical Review, or Clinical Compliance. 3+ years of leadership or supervisory experience.
- Strong knowledge of CMS regulations, state UM requirements, NCQA/URAC standards, and medical necessity criteria (InterQual, MCG).
- Experience with compliance audits, CAP development, and regulatory monitoring.
Professional Certification(s):- Registered Nurse with current State of Ohio license required.
Technical Skills and Knowledge:- Comprehensive knowledge of prior authorization operations, clinical review workflows, utilization management, and benefit interpretation.
- Comprehensive knowledge of InterQual, MCG, Corporate Medical Policies, clinical documentation, and medical necessity criteria.
- Strong knowledge of CMS, state UM requirements, NCQA/URAC standards, HIPAA, NQTLs, audits, and corrective action processes.
- Strong knowledge of claims processing, medical terminology, payment analysis, cost containment, ICD-10, CPT, and HCPCS coding.
- Knowledge of managed care, care coordination, disease progression, levels of care, patient outcomes, and community resources.
- Ability to analyze KPIs, identify trends, prepare reports, and support performance improvement initiatives.
- Proficiency with Microsoft Office, Excel reporting, prior authorization platforms, and clinical decision-support tools.
- Strong communication, collaboration, vendor partnership, change leadership, and staff development 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.
- 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.
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