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Benefit Implementation Specialist
Medical Mutual - Cleveland, OH
Interacts with the Sales Department and customers to define and finalize medical, drug, vision and dental benefit designs for all market segments. Ensures benefits can be systematically administered and meet state and federal mandates. Coordinates workflow among the Sales, Membership, Certificate Development, Actuarial and Underwriting Departments to expedite group/products installation.
Operations Specialist
Medical Mutual - Cleveland, OH
Coordinates workflow in assigned unit(s) to include audit, systems, processes, operations and policies. Analyzes workflow systems and provides recommendations to management for process improvements. Maintains control of the daily operational functions assigned to the unit. Provides analytical and technical expertise to assist staff and/or directly respond to escalated and/or ...
Data Engineering Developer II*
Medical Mutual - Cleveland, OH
External Notice Medical Mutual of Ohio seeking multiple Data Engineering Developer II to design and develop data lake, data warehouse and data marts for business intelligence dashboards and visualizations in Strongsville, OH. Will use business and data modeling concepts, stakeholder analysis, and objectives support to solve business problems. Will profile data, develop ...
Medical/Utilization Management Specialist II
Medical Mutual - Cleveland, OH
Performs all duties of an administrative and technical nature including investigating and processing claims and maintaining and updating medical and physician files in order to provide an effective daily operation of the department. Responsibilities Answers phone/ fax inquiries from providers, members, and internal departments to provide assistance and claim status informat...
Manager, Server, Web Application and Cloud Support
Medical Mutual - Strongsville, OH
Please note that this role will be working from the new Brooklyn facility by mid-2020. This position oversees the daily operation and technical advancement of the Server, Web Application and Cloud Support department. The Server, Web Application and Cloud manager is primarily responsible for: 16 Direct Reports plus occasional contractors Developing ...
Talent Sourcer
Medical Mutual - Cleveland, OH
As the oldest and one of the largest health insurance companies in Ohio, Medical Mutual provides health insurance to more than 1.6 million Ohioans. For more than 85 years, Medical Mutual has improved the lives of its members by offering high-quality group and personal healthcare coverage. Medical Mutual has been selected as a Northeast Ohio Top Workplace by the Plain Deale...
Manager, Claims & Disbursements Systems
Medical Mutual - Cleveland, OH
Manages Medical Mutual's systems development technical staff to ensure the effective execution of projects – on time, on scope, on budget – to implement, enhance, and maintain the Company's claims and disbursements applications. Builds relationships with peer business leaders and provide day-to-day leadership and management to ensure alignment of resources and application solutions to addres...
Pharmacist, Manager Pharmacy Quality (STARS/NCQA)
Medical Mutual - Cleveland, OH
Directs STARS strategy for all STAR measures where Pharmacy has responsibility and manages activities and staff to support obtaining the highest STARS ratings. Conducts NCQA support for delegation oversight for Utilization Management for Pharmacy and Medical Drug Management programs. Works with corporate quality department to incorporate quality info Pharmacy and Medical Drug Management process...
Prior Authorization Nurse Reviewer
Medical Mutual - Cleveland, OH
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 provid...
Stop Loss Proposal Coordinator-TPA
Medical Mutual - Brooklyn, OH
Assists in the development, completion and submission of bids and proposals for prospects, clients and vendors. Gathers information internally and from other vendors to assimilate into the appropriate responses that best reflect the customer needs. Develops and improves language and materials for the completion of informational and pricing requests. This role will be positio...
Senior Provider Experience Program Analyst
Medical Mutual - Cleveland, OH
Evaluates inputs from corporate initiatives, business goals, department and company stakeholders and provider feedback in order to develop, maintain and promote the Product Roadmap(s) and Provider Journey maps. Leads the discovery and intake phases of product planning and manages or participates in related processes around prioritization, definition, and product strategy. Develops business c...
Contracting Coordinator
Medical Mutual - Strongsville, OH
Assists Contractors and Management by maintaining familiarity with each account and their designated representative(s), understanding provider contracts, and fielding calls/concerns that occur. In addition, prioritizes and researches problems affecting providers and maintains up to date contract and contract management files and documentation. Responsibilities:
Medicare Pharmacy Coordinator
Medical Mutual - Cleveland, OH
The Medicare Pharmacy Coordinator is responsible for the successful operations and compliant administration of the Medicare Part D (pharmacy) program. Assuring accurate and consistent configuration, implementation administration, maintenance, monitoring, processing of pharmacy benefits including ongoing support for the Medicare Part D Individual and EGWP benefit requirements. Daily Responsibili...
Senior Healthcare Analyst (Policy Writer)
Medical Mutual - Cleveland, OH
Provides support to the health plan in creating and maintaining policies used in clinical review process along with assistance in researching new technologies presented to the plan for reimbursement consideration. This individual will also be responsible in managing and performing the process used to assure all policies used in medical necessity determinations remain compliant with NCQA require...
Assistant Medical Director
Medical Mutual - Cleveland, OH
Medical Mutual has an immediate need for an Assistant Medical Director, to join our team of physician reviewers. A Pediatrician or a Surgical Specialty (Ortho/General) is highly preferred. Provides clinical expertise to the utilization review process and determinations. Provides pre-determination reviews and reviews of claims determinations, providing clinical, coding ...
