Under limited supervision, applies medical necessity guidelines in making authorization determinations for inpatient admissions, concurrent, and retrospective reviews in collaboration with physician reviewers. Applies evidence-based discharge planning so that patients have a safe and timely transition to next appropriate level of care.
- Evaluates clinical information using established national decision support criteria, company policies, and individual patient considerations to ensure the provisions of safe, timely, and appropriate covered healthcare services.
- Independently conducts basic to complex emergency and acute care admissions, concurrent, and retrospective reviews of inpatient admissions, to ensure compliance with criteria guidelines, member eligibility, benefits and contracts.
- Plans, implements, and documents, discharge planning activities based on the members' specific clinical condition, health plan benefits, and optimal care delivery. Acts as a resource to the provider community, explaining processes for accessing the Company's website to identify network providers for next level of care and post-discharge follow-up care
- Promotes effective resource management by directing member care to accessible cost-effective post-acute network providers and 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 with designated external vendors and Assistant Medical Directors, social workers and case managers to determine potential high dollar member costs, discharge planning interventions that ensure delivery of consistent and quality health care services.
- Keeps up to date on utilization management regulations, policies and practices.
- 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.
- Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor's degree preferred.
- 3 years as a Registered Nurse with a combination of clinical and or utilization/case management experience, preferably in the health insurance industry.
- Acute inpatient level of care in Medical/Surgical/Critical Care/ ambulatory care experience preferred.
- Registered Nurse with current State of Ohio unrestricted license.
- Intermediate Microsoft Office skills and proficiency navigating windows and web-based systems.
- Knowledge of, and the ability to apply fundamental concepts related to HIPAA compliance and related regulations.
- Knowledge of clinical practices and efficient care delivery processes.
- Performs work in an office setting with moderate levels of noise, sitting for long periods of time, using computers and phones, and with exposure to fluorescent lighting.
- Ability to occasionally travel offsite for on-going training.
- Ability to occasionally work weekends and extended hours as needed.
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 locations
- Employee discount program. Discounts at many places in and around town, just for being a Medical Mutual team member
- Business Casual attire
Excellent Benefits and Compensation:
- Competitive compensation plans
- Employee bonus program
- 401(k) with company match and an additional company contribution
- Excellent medical, dental, vision, and disability insurance
An Investment in You:
- Career development programs and classes
- Mentoring and coaching to help you advance
- Education 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.
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