Supervisor, Clinical Operations

Job Category : Clinical Appeal & Claim Review Posted : July 16, 2026 Full-Time Hybrid Locations Cleveland, OH 44144, USA Description Medical Mutual employees must submit their applications through MySource. Note: This is a hybrid role requiring 3 days per week on-site in our Brooklyn, Ohio office. Supervises staff, workflow, and quality of Clinical Appeal and Claim Review operations. Ensures compliance with government regulations and Company policies and procedures. Identifies operational issues, makes recommendations for improvements, and aids in implementation of procedural and systemic changes. 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 and 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 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. 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. 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. We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr Superior Dental Care, Inc.