Reports to: Manager
Serves as a member of the Care Management team, performing utilization management activities to ensure the provision of safe, timely, appropriate, and necessary covered healthcare services to members; promoting effective resource management by directing member care to accessible cost-effective network providers and services at the appropriate level of care; and facilitating timely discharge planning and continuity of care across healthcare settings. Provides educational assistance to providers and physicians regarding covered and non-covered care for medical/surgical and /or psychiatric claims, as well as appropriate network utilization. Supports the care management department by performing some duties of an administrative and technical nature, including investigation and processing of claims.
• Evaluates clinical information using established national decision support criteria, Medical Mutual policies, individual patient considerations, and clinical judgment to determine appropriateness of services and procedures. Refers cases that are complex or outside the established criteria and guidelines to the Physician Advisor
• Manages initial, concurrent, and retrospective review of cases, including appeals
• Identifies and refers members with potential health care needs to case and health management services.
• Coordinates with other care management departments to ensure the timely provision of covered health care services
• Meets department standards for accuracy, quality and documentation in order to communicate decisions in an appropriate and timely manner.
• Initiates and maintains positive relationships with internal and external customers.
• Complies with organizational policies related to code of conduct, confidentiality, and financial compensation
• Maintains working knowledge of contracting arrangements and group benefits, and administers benefits within the plan limitations.
• Maintains a working knowledge of applicable accreditation and regulatory requirements.
• Participates in continuing nursing and medical education classes to assist in understanding new treatment concepts and their incorporation into current practice.
• Maintains a working knowledge of, and interfaces with, key business units within Medical Mutual to facilitate proper adjudication of claims and services to members.
• Must be either a Registered Nurse (preferred) with three years recent nursing experience with State of Ohio license.
• Two years current medical/surgical and/or psychiatric nursing experience.
• Effective interpersonal and verbal and written communication skills.
• Demonstrated analytical and organizational skills.
• Knowledge with medical terminology/coding and managed care processes.
• Personal Computer skills using Windows-based programs and applications.
• Time management and problem solving skills.
• Ability to work independently, managing multiple tasks and priorities within designated time frames.
Physical Demands/Work Environment
• Performs work in an office environment in which there is minimal exposure to unpleasant and/or hazardous working conditions.
• Work is performed mostly while sitting, often for long periods of time using telephone and PC.
• Some standing, stooping, bending, lifting and walking is required.
• Work may require concentration and attention to accuracy and detail for extended time periods.
We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse and tobacco testing
Medical Mutual of Ohio is a not-for-profit managed care company that provides health insurance products and related services to some 1.6...