Description
**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.
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.
Job Summary:
Functions independently as a subject matter expert for Case Management and Utilization Management population health programs. Leads and co-leads cross-functional projects and initiatives related to people, process and technology. Coordinates and facilitates use of system tools and process workflow with providers, health system partners, vendors and subcontractors. Develops provider integration and departmental process and works with internal departments, external customers (employer groups) and providers regarding training, education, and communication. Conducts post-implementation evaluation and drives continuous process improvement. Develops, maintains and delivers group policy and procedures and training for new hires and existing staff, and documentation and edits to clinical program description. Manages annual and PRN clinical audit in compliance with NCQA and regulatory standards and the development, administration and scoring of Inter-rater reliability audits for staff, as appropriate.
Responsibilities:
- Acts as project leader in the development and review of procedures and systems relating to internal departmental work as well as with other departments. Develops tools, workflows, and documentation to support new processes as required. Conducts post implementation evaluation and drives continuous process improvement.
- Acts as a primary liaison to other internal and external customers in reviewing/researching and developing solutions to identified issues and concerns. Prepares written documentation and analysis of clinical cases and other needed reports.
- Leads, coordinates, and tests system implementation and updates with IT systems and external vendors. Provides team education, coaching and auditing relating to system and departmental changes.
- Delivers training and coaching to internal staff on policies and procedures, Inter-Rater Reliability, InterQual® (IQ) guidelines for evaluating medical necessity and compliance with NCQA and regulatory program requirements where applicable. As assigned, develops and delivers education, training and documentation to providers and /or groups regarding the Company's programs and system tools including reference documents, job aids and education specific to corporate clinical portals.
- 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.
- 5 years experience as a Registered Nurse which includes progressive experience as a Nurse Reviewer or Case Manager or equivalent experience in patient-centered care, utilization management, quality improvement, credentialing, case management, or discharge planning activities.
- Health plan experience (especially internal) strongly preferred.
Professional Certification(s):
- Registered Nurse with current State of Ohio unrestricted license required.
Technical Skills and Knowledge:
- Comprehensive knowledge of clinical practices, managed care processes, members' specific health plan benefits and network plan design, and efficient care delivery processes.
- Comprehensive knowledge of, and the ability to apply fundamental concepts related to accreditation and HIPAA compliance and related regulations.
- Strong understanding of the utilization management, credentialing, delegation, and/or quality improvement processes.
- Understanding of medical coding as it relates to diagnosis and procedures
- Demonstrated leadership skills with excellent oral, written, and interpersonal skills;
- Works independently, managing multiple tasks and priorities within designated time frame
- Intermediate Microsoft Office skills and proficiency navigating Windows-based programs and applications and web-based systems
- Strong analytical and problem solving skills and organizational and documentation skills
- Coaching and mentoring skills
- Project leadership 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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