Utilization Management Nurse Reviewer-Care Authorizations

  • Medical Mutual
  • Cleveland, OH, USA
  • Nov 03, 2017
Full time Health Care

Job Description

Utilization Management Nurse Reviewer-Care Authorizations Description

*Competitive pay and sign on bonus*

Performs utilization management activities to ensure the provision of safe, timely, appropriate, and necessary covered healthcare services to members; promotes effective resource management by directing member care to accessible cost-effective network providers and services at the appropriate level of care; and facilitating timely discharge planning and continuity of care across healthcare settings. Provides educational assistance to providers and physicians regarding covered and non-covered care for medical/surgical and/or psychiatric claims as well as appropriate network utilization. #cb

ESSENTIAL FUNCTIONS:

Evaluates clinical information using established national decision support criteria, Medical Mutual policies, individual patient considerations, and clinical judgment to determine appropriateness of services and procedures. Refers cases that are complex or outside the established criteria and guidelines to the Physician Advisor. Manages initial, concurrent and retrospective review of cases, including appeals. Initiates and maintains positive relationships with internal and external customers. Meets department standards for accuracy, quality and documentation in order to communicate decisions in an appropriate and timely manner. Identifies and refers members with potential health care needs to case and health management services. Coordinates with other care management departments to ensure the timely provision of covered health care services.

Qualifications

Registered Nurse with 3 years recent nursing experience with State of Ohio license

3 years current medical/surgical experience.

Knowledge with medical terminology/coding and managed care processes.

Personal Computer skills using Windows-based programs and applications, including Basic MS 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:

Top Workplace in Northeast Ohio. Five years in a row we've received this recognition!

On-site wellness center and massage. Enjoy personal trainers, towel service, locker room, weight room, elliptical machines, and a variety of classes!

On-site cafeteria serving hot breakfast and lunch. Choices ranging from salad bar, made to order, hot and cold sandwiches, or a variety of entrees cooked fresh daily

Convenient store

Employee discount program. Discounts at many places in and around town, just for being a Medical Mutual team member

Business casual attire

Excellent Benefits and Compensation:

Competitive compensation plans

Employee bonus program

Healthcare

401(k) with company match and an additional company contribution

Excellent medical, dental, vision, and disability insurance

An Investment in You:

Career development programs and classes

Mentoring and coaching to help you advance

Education reimbursement up to $5K per year

About Medical Mutual:

We strive to create peace of mind. Our customers can trust us to do things right and to help them get value from their health plan. We're the largest health insurer in Ohio and for 80 years, we've been serving our members and the Ohio communities where they live and work. Medical Mutual is a Top Place to Work in Northeast Ohio with exceptional career opportunities that offer challenge, growth and a great work/life balance. We want talented, innovative, and driven people to help us continue to be the best health insurance choice of Ohioans and help make Ohio the best it can be! Our headquarter building is located in the heart of downtown Cleveland and we have multiple offices throughout the state. Join us at one near you!

At Medical Mutual we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.

Primary Location : US-OH-Cleveland Work Locations : Cleveland - Headquarters 2060 East Ninth Street Cleveland 44115 Schedule : Full-time Job Posting : Aug 9, 2017, 9:18:18 PM