**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:Supervises prior authorization utilization review nurses ensuring they appropriately apply medical necessity guidelines in making authorization determinations for preservice procedures and surgeries, in collaboration with physician reviewers. Oversees processes to support evidence-based guidelines, Corporate Medical Policies and other decision support tools to ensure comprehensive cost-effective care for members.
Responsibilities:- Supervises daily operations of assigned Prior Authorization Nurse Reviewers. Ensures appropriate use of staff resources to facilitate accurate and timely utilization management decisions in collaboration with physician reviewers.
- Supports staff onboarding, training, and professional development including maintenance of current knowledge of approved criteria and evidence-based practice to support the delivery of high quality, efficient utilization management authorization determinations
- Ensures that staff appropriately gather the requisite data and information to enter authorizations and tracks and monitors the accuracy and timelines of data entered
- Evaluates the quality of individual and group performance to ensure that that team is meeting departmental and organizational goals related to utilization, cost, quality and productivity targets.
- Ensures compliance with company policy and procedure as well as state and federal rules and regulations and accreditation standards.
- Assists management in coordinating facility system process with providers, partners, vendors, and subcontractors as necessary
- 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.
- 7 years progressive experience as a Nurse Reviewer in health insurance prior authorization or clinical appeals, or equivalent relevant RN experience in a clinical practice
- Relevant experience leading teams or projects (formally or informally)
Professional Certification(s):- Registered Nurse with current State of Ohio unrestricted license.
Technical Skills and Knowledge:- Intermediate Microsoft Office skills and proficiency navigating windows and web-based systems.
- Knowledge of medical terminology/coding managed care processes
- Knowledge of and the ability to apply fundamental concepts related to HIPAA compliance and related regulations
- Knowledge of disease continuums expected patient outcomes and community services available
- Strong knowledge of clinical claim management including ICD 10, CPT and HCPCS code
- Strong knowledge of health insurance benefits and network plan designs
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.
#LI-CS1 #LI-HYBRID 
