Supervisor, Clinical Operations

Medical Mutual; Cleveland (OH); Hybrid; USD 70,000 - 100,000; Full time

Benefits offered by this job

401(k) with company match

Health insurance

Paid time off

Parental leave

Tuition reimbursement

Job summary

Medical Mutual in Ohio seeks a Senior Clinical Appeals Nurse to supervise clinical staff, review complex medical appeals, and ensure compliant utilization management. You will collaborate with physicians, providers, and internal teams to ensure appropriate and timely care.

Qualified candidates are RNs licensed in Ohio with 7+ years of progressive experience in clinical appeals or health insurance and a Bachelor’s degree preferred. Hybrid role with on-site in Brooklyn, OH.

Qualifications

• Graduate of a registered nursing program; Bachelor’s Degree preferred.
• 7 years progressive RN experience including senior clinical appeals or equivalent in health insurance.
• Licensed RN in Ohio with strong leadership and project experience.

Responsibilities

• Supervises clinical and support staff evaluating medical claims and appeals.
• Reviews production and quality data; conducts audits of cases; may collaborate with physician team.
• Manages workflow, escalated issues, and implements program changes.
• Participates in staffing, performance management and staff development.
• Ensures compliance with utilization management regulations and coding practices.
• Maintains timely written status updates to providers, members, and regulators.
• Acts as a resource to providers and internal departments to ensure appropriate care.

Skills

Clinical leadership

Regulatory compliance

ICD-10 knowledge

Healthcare coding

Microsoft Office

Coaching for results

Education

Nursing degree

RN license (Ohio)

Tools

Microsoft Office

Job description

Overview

Medical Mutual employees must submit their applications through MySource. This is a hybrid role requiring 3 days per week on-site in our 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.

Medical Mutual is looking to grow our team. We truly value and respect the talents and abilities of all of our employees. We offer an exceptional package that includes benefits and compensation as described below.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing. This employer is an Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities. See Know Your Rights notice for more information.

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. May review sensitive or more complex cases.
• Reviews production and quality data to ensure accuracy and consistent application of policies and procedures. Conducts quality audits of cases reviewed by staff. Reviews quality of documentation provided to physician review or other external review. May collaborate directly with physician team on escalated reviews.
• Supervises and assigns workflow and handles escalated issues. Monitors and evaluates the effectiveness of programs and procedures. Identifies operational inefficiencies and recommends improvements. Develops, tests, and implements system and process changes.
• Participates in staffing, performance management and training and development of staff.
• Ensures staff keeps up to date on utilization management regulations, policies and practices, including applicable coding, and that policies and procedures are updated accordingly.
• Ensures timely and accurate written status of review to providers, members, and regulatory entities advising of status. Monitors and ensures compliance with accreditation and regulatory requirements.
• Acts as a resource to the provider community, explaining processes for accessing health plan to perform clinical review, identifying appropriate community resources, or otherwise interacting with health plan programs and services. Collaborates with providers, members and various internal departments 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 preferred.
• 7 years progressive experience as a Registered Nurse, which includes experience as a Senior Clinical Appeals Nurse or equivalent relevant experience in the health insurance industry.
• Relevant experience leading teams or projects (formally or informally).

Professional Certification(s):

• Registered Nurse with current State of Ohio unrestricted license.

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.
• Coaches for results.
• Ability to facilitate change and produce results.
• Business acumen and cost awareness.
• Knowledge of change management and quality improvement fundamentals.

Benefits and Perks

• 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.
• Access to an Employee Assistance Program, including counseling and coaching resources.
• Company holidays and up to 16 PTO days during the first year with carryover options.
• Parental leave after 120 days of service for eligible employees.
• Career development programs and mentoring; tuition reimbursement up to $5,250 per year.
• Diverse, inclusive 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. We focus on products and services that better serve customers and communities, including a broad portfolio of health, life, disability, dental, vision and indemnity plans.

We are trusted by businesses and nonprofit organizations throughout Ohio and serve more than 1.2 million Ohioans with our plans. We are one of the largest health insurance companies in Ohio and have a long history in the communities where we live and work.

Note: This job description contains information about the role and qualifications. #LI-JT1