Description
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.
Manages the assessment of the effectiveness of clinical coding and claims payment policies and procedures. Analyzes results of findings, researches best practices/trends, and makes recommendations for efficiencies and cost savings. Partners with other departments, information technology, and vendors to implement solutions.
Responsibilities
- Manages the review and analyses of clinical coding and medical policies and procedures and how they impact claim payments.
- Manages Clinical Review & Recovery Analyst to improve the quality and oversight of the clinical coding and claims payment auditing program.
- Monitors all department specific data reports, outcome analysis and resource allocation.
- 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.
- 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.
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.
About Medical Mutual:
Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.
There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide 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. Our plans provide peace of mind to more than 1.2 million Ohioans.
We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
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