Director, Appeals & Claim Review

**Medical Mutual employees must submit their applications through MySource.

Note: This is a hybrid role requiring 4 days per week on-site in our Brooklyn, Ohio office. Seeking applicants that reside within a 50-mile radius of the Brooklyn, Ohio office.

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.

Directs staff and operations of Clinical and administrative appeals and claims review. Ensures compliance with government regulations, Company policies and procedures, performance guarantees and accreditation standards. Implements procedural and systemic changes. Establishes performance metrics and ensures accountability. Cross collaborates with clinical and non-clinical management across the organization to support corporate goals.

Responsibilities:

• Develops and directs standard operating procedures for the evaluation of claims and all appeal cases. Determines processes to assess the appropriateness of service provided, length of stay and level of care. Proactively identifies risks within the processes or procedures relating to regulatory requirements and compliance.
• Monitors and evaluates the effectiveness of programs and procedures. Analyzes trends in data related to IRO and IRE determinations, case quality, financial and other audit sources. Leads improvements in key performance initiatives.
• Develops effective relationships with key partners within the organization and works directly with physician leaders on escalated issues, determinations, and/or regulatory requirements.
• Manages budget and cost containment efforts. Directs the oversight of staffing, performance management and training and development of clinical and administrative staff.
• Ensures staff keeps up to date on relevant regulations, policies and practices, including applicable coding, and that policies and procedures are updated accordingly.
• Directs the oversight of timely and accurate written status of review to providers, members, and regulatory entities. Monitors and ensures compliance with accreditation and regulatory requirements for clinical and administrative appeals and claims reviews.
• Partners with the provider community, participates in joint operating committees and project work groups. Collaborates with providers, members and across the organization 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 in related field required.
• 8 years progressive experience as a Registered Nurse, which includes experience as a Supervisor in Clinical Appeal & Claim Review, or equivalent experience in the health insurance industry.

Professional Certification(s):

• Registered Nurse with current State of Ohio license required.

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.
• Ability to lead for optimal effectiveness.
• Ability to facilitate change and produce results.
• Business acumen and ability to manage budgets to achieve financial goals.
• Strong change management leadership skills.
• Ability to lead quality improvement initiatives.

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. #LI-JT1