Clinical Appeal & Claim Review Nurse I

Note: This is a remote position. Seeking applicants who reside with 50 miles of the Brooklyn office. Certified Medical Coder (CPC, CCS, or equivalent) credential preferred. 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. Working under general supervision, builds and applies knowledge to evaluate clinical information using evidence-based guidelines, company policies and individual patient considerations to ensure the provisions of safe, timely and appropriate healthcare services. Promotes effective use of resources and provides assistance to members in managing their health care across the continuum of care. Responsibilities: Evaluates basic to moderately complex medical claims and/or appeal cases and associated records by applying clinical, regulatory, and policy and procedures knowledge and experience to assess the appropriateness of service provided, length of stay and level of care. Extrapolates and summarizes medical information for physician review or other external review. Generates appropriate written status of review to providers, members, and regulatory entities advising of status. 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. Keeps up to date on utilization management regulations, policies and practices, including applicable coding. Collaborates with more senior level staff on escalated claims and appeals records. 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. 1 to 3 years of experience as a Registered Nurse in acute care, critical care, emergency medical or medical surgical or a combination of clinical and utilization/case management experience in the health insurance industry. Experience in clinical documentation improvement, medical coding or medical documentation investigation preferred. Professional Certification(s): Registered Nurse with current State of Ohio unrestricted license. Technical Skills and Knowledge: Clinical knowledge and understanding of health care delivery processes. Knowledge of medical terminology and managed care processes. Knowledge of clinical claim management including ICD 10, CPT, HCPC, and revenue codes. Knowledge of health care regulations. Computer navigation and keyboarding proficiency; Intermediate Microsoft Office skills. 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. 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. 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 Medical Mutual