Medical Mutual
Prior Authorization Nurse Reviewer
Medical Mutual, Columbus, Ohio, United States,
Note:
This position allows you the flexibility to work at home within the state of Ohio. We are looking for applicants that have a strong clinical utilization management background. Medicare experience is a plus.
Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
Under limited supervision, promotes effective use of, and provides appropriate resources and assistance to members managing their health care across the continuum of care. Applies evidence-based criteria and benefit interpretations to make coverage decisions. Collaborates with providers, members and various internal departments to effectively direct care to quality cost-effective network providers at the appropriate level of care.
Responsibilities
• Conducts pre-certification of basic to complex outpatient services, surgical and diagnostic procedures, and out of network services to ensure compliance with medical policy, member eligibility, benefits and contracts.
• Evaluates clinical information using established national decision support criteria, company policies, and individual patient considerations to ensure the provisions of safe, timely, and appropriately covered healthcare services.
• Promotes effective resource management by directing member care to accessible cost- effective network providers and coordinates services at appropriate level of care. Coordinates with other Pharmacy and Care Management departments to facilitate the timely provision of covered health care services.
• Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Assists Claims and/or Customer Care Departments as applicable.
• Keeps up to date on utilization management regulations, policies and practices, including applicable coding.
• If assigned to Preceptor/Trainer task: Orients, trains and provides guidance to more junior or less experienced staff. Supports implementation of new procedures, processes or clinical systems.
• Performs other duties as assigned.
Qualifications
Education and Experience:
• Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor's degree preferred.
• 3 years' experience as a Registered Nurse with a combination of clinical and utilization/case management experience, preferably in the health insurance industry.
• Acute care Medical/Surgical/Critical Care and ambulatory care experience preferred.
Professional Certification(s):
• Registered Nurse with current State of Ohio unrestricted license.
Technical Skills and Knowledge:
• Strong knowledge of health insurance benefits and network plan designs.
• Knowledge of, and the ability to apply fundamental concepts related to HIPAA compliance and related regulations.
• Ability to apply knowledge of health plans and industry trends to achieve positive outcomes.
• Knowledge of clinical practices, members' specific health plan benefits, and efficient care delivery processes.
• Intermediate Microsoft Office skills and proficiency navigating windows and web based systems.
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:Top Workplace in Northeast Ohio. Year after year we've received this recognition!On-site wellness center at most locations. Enjoy personal trainers, towel service, locker room, weight room, elliptical machines, and a variety of classes!On-site cafeteria serving hot breakfast and lunch, at most locations. Choices ranging from salad bar, made to order, hot and cold sandwiches, or a variety of entrees cooked fresh daily. Convenience store at most locationsEmployee discount program. Discounts at many places in and around town, just for being a Medical Mutual team memberBusiness Casual attire
Excellent Benefits and Compensation:Competitive compensation plansEmployee bonus program401(k) with company match and an additional company contributionExcellent medical, dental, vision, and disability insurance
An Investment in You:Career development programs and classesMentoring and coaching to help you advanceEducation reimbursement up to $5K per year
About Medical Mutual:
We strive to create peace of mind. Our customers can trust us to do things right and to help them get value from their health plan. We're the largest health insurer in Ohio and for over 85 years, we've been serving our members and the Ohio communities where they live and work. Medical Mutual is a Top Place to Work in Northeast Ohio with exceptional career opportunities that offer challenge, growth and a great work/life balance. We want talented, innovative, and driven people to help us continue to be the best health insurance choice of Ohioans and help make Ohio the best it can be! Our headquarter building is located in the heart of downtown Cleveland and we have multiple offices throughout the state. Join us at one near you!
At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
This position allows you the flexibility to work at home within the state of Ohio. We are looking for applicants that have a strong clinical utilization management background. Medicare experience is a plus.
Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
Under limited supervision, promotes effective use of, and provides appropriate resources and assistance to members managing their health care across the continuum of care. Applies evidence-based criteria and benefit interpretations to make coverage decisions. Collaborates with providers, members and various internal departments to effectively direct care to quality cost-effective network providers at the appropriate level of care.
Responsibilities
• Conducts pre-certification of basic to complex outpatient services, surgical and diagnostic procedures, and out of network services to ensure compliance with medical policy, member eligibility, benefits and contracts.
• Evaluates clinical information using established national decision support criteria, company policies, and individual patient considerations to ensure the provisions of safe, timely, and appropriately covered healthcare services.
• Promotes effective resource management by directing member care to accessible cost- effective network providers and coordinates services at appropriate level of care. Coordinates with other Pharmacy and Care Management departments to facilitate the timely provision of covered health care services.
• Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Assists Claims and/or Customer Care Departments as applicable.
• Keeps up to date on utilization management regulations, policies and practices, including applicable coding.
• If assigned to Preceptor/Trainer task: Orients, trains and provides guidance to more junior or less experienced staff. Supports implementation of new procedures, processes or clinical systems.
• Performs other duties as assigned.
Qualifications
Education and Experience:
• Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor's degree preferred.
• 3 years' experience as a Registered Nurse with a combination of clinical and utilization/case management experience, preferably in the health insurance industry.
• Acute care Medical/Surgical/Critical Care and ambulatory care experience preferred.
Professional Certification(s):
• Registered Nurse with current State of Ohio unrestricted license.
Technical Skills and Knowledge:
• Strong knowledge of health insurance benefits and network plan designs.
• Knowledge of, and the ability to apply fundamental concepts related to HIPAA compliance and related regulations.
• Ability to apply knowledge of health plans and industry trends to achieve positive outcomes.
• Knowledge of clinical practices, members' specific health plan benefits, and efficient care delivery processes.
• Intermediate Microsoft Office skills and proficiency navigating windows and web based systems.
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:Top Workplace in Northeast Ohio. Year after year we've received this recognition!On-site wellness center at most locations. Enjoy personal trainers, towel service, locker room, weight room, elliptical machines, and a variety of classes!On-site cafeteria serving hot breakfast and lunch, at most locations. Choices ranging from salad bar, made to order, hot and cold sandwiches, or a variety of entrees cooked fresh daily. Convenience store at most locationsEmployee discount program. Discounts at many places in and around town, just for being a Medical Mutual team memberBusiness Casual attire
Excellent Benefits and Compensation:Competitive compensation plansEmployee bonus program401(k) with company match and an additional company contributionExcellent medical, dental, vision, and disability insurance
An Investment in You:Career development programs and classesMentoring and coaching to help you advanceEducation reimbursement up to $5K per year
About Medical Mutual:
We strive to create peace of mind. Our customers can trust us to do things right and to help them get value from their health plan. We're the largest health insurer in Ohio and for over 85 years, we've been serving our members and the Ohio communities where they live and work. Medical Mutual is a Top Place to Work in Northeast Ohio with exceptional career opportunities that offer challenge, growth and a great work/life balance. We want talented, innovative, and driven people to help us continue to be the best health insurance choice of Ohioans and help make Ohio the best it can be! Our headquarter building is located in the heart of downtown Cleveland and we have multiple offices throughout the state. Join us at one near you!
At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.