Supervisor, Clinical Operations Job Listing at Medical Mutual in OH (Job ID 2500146)

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.

Supervises staff, workflow, and quality of Clinical Appeal and Claim Review operations. Ensures compliance with government regulations and Company policies and procedures. Identifies operational issues, makes recommendations for improvements, and aids in implementation of procedural and systemic changes. 

Responsibilities

• Supervises clinical and support staff evaluating medical claims and/or appeal cases and associated records to assess the appropriateness of service provided, length of stay and level of care.  May review sensitive or more complex cases.
• Reviews production and quality data to ensure accuracy and consistent application of policies and procedures.  Conducts quality audits of cases reviewed by staff. Reviews quality of documentation provided to physician review or other external review. May collaborate directly with physician team on escalated reviews
• Supervises and assigns workflow and handles escalated issues. Monitors and evaluates the effectiveness of programs and procedures.  Identifies operational inefficiencies and recommends improvements.  Develops, tests, and implements system and process changes
• Participates in staffing, performance management and training and development of staff.
• Ensures staff keeps up to date on utilization management regulations, policies and practices, including applicable coding, and that policies and procedures are updated accordingly.
• Ensures timely and accurate written status of review to providers, members, and regulatory entities advising of status. Monitors and ensures compliance with accreditation and regulatory requirements.
• Acts as a resource to the provider community, explaining processes for accessing health plan to perform clinical review, identifying appropriate community resources, or otherwise interacting with health plan programs and services. Collaborates with providers, members and various internal departments to ensure that members are getting appropriate care at the most appropriate time
• 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.
• 7 years progressive experience as a Registered Nurse, which includes experience as a Senior Clinical Appeals Nurse or equivalent relevant experience in the health insurance industry
• 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:

• Comprehensive clinical knowledge and understanding of health care delivery processes.
• Comprehensive knowledge of medical terminology and managed care processes.
• Comprehensive knowledge of clinical claim management including ICD 10, CPT, HCPC, and revenue codes and ability to apply advanced concepts
• Comprehensive knowledge of health care regulations applicable to health insurance industry and ability to apply to Company policies and procedures.
• Computer navigation and keyboarding proficiency; Intermediate Microsoft Office skills.
• Coaches for results.
• Ability to facilitate change and produce results.
• Business acumen and cost awareness.
• Knowledge of change management and quality improvement fundamentals.

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.

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. #LI-JT1 #LI-REMOTE