Senior Clinical Operations Leader

Medical Mutual; Brooklyn (OH); Hybrid; USD 95,000 - 115,000; Full time

Benefits offered by this job

Bonus program

401(k) with company match up to 4%

Health Savings Account with company co

Excellent medical, dental, vision, and

PTO and holidays

Parental leave

Tuition reimbursement

Career development programs

Job summary

Medical Mutual is hiring a Senior Clinical Appeals Nurse to supervise clinical and support staff evaluating medical claims and appeal cases, ensuring appropriate care and adherence to policies. The role requires RN licensure in Ohio with 7 years of progressive nursing experience, including leadership of teams or projects.

The position is hybrid, based in Brooklyn, Ohio, and entails staying current with utilization management regulations while guiding staff through complex reviews and regulatory

Qualifications

• Graduate of a registered nursing program approved by the Ohio State Nursing Board.
• 7 years progressive experience as a Registered Nurse, including Senior Clinical Appeals Nurse or equivalent in health insurance.
• Relevant experience leading teams or projects.

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.
• Reviews production and quality data to ensure accuracy and consistent application of policies and procedures and conducts quality audits.
• Collaborates with physician team on escalated reviews and may review sensitive or complex cases.
• Participates in staffing, performance management and training and development of staff.
• Ensures staff stays up to date on utilization management regulations and that policies are updated accordingly.
• Ensures timely and accurate written status of review to providers, members, and regulatory entities.

Skills

Clinical knowledge

Regulatory knowledge

Coaching for results

Change management

Microsoft Office

Education

Ohio RN license

Bachelor’s degree preferred

Tools

ICD-10 coding

CPT coding

HCPCS coding

Revenue codes

Job description

Medical Mutual is hiring a Senior Clinical Appeals Nurse to supervise clinical and support staff evaluating medical claims and appeal cases, ensuring appropriate care and adherence to policies. The role requires RN licensure in Ohio with 7 years of progressive nursing experience, including leadership of teams or projects.

The position is hybrid, based in Brooklyn, Ohio, and entails staying current with utilization management regulations while guiding staff through complex reviews and regulatory