RN Clinical Appeals

3 weeks ago

Brooklyn, United States Medical Mutual Full time

This position allows you the flexibility to work at home. We are looking for applicants that have a strong clinical utilization management background. Medicare experience is a plus.


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 limited supervision, evaluates 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:


Independently evaluates basic to 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

Orients, trains, and provides guidance to more junior or less experienced staff. Facilitates work assignments

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

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

3 years’ 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:

Registered Nurse with current State of Ohio unrestricted license


Technical Skills and Knowledge:

Strong clinical knowledge and understanding of health care delivery processes

Familiarity with medical terminology and managed care processes

Familiarity with clinical claim management including ICD 10, CPT, HCPC, and revenue codes

Familiarity with health care regulations

PC and keyboarding proficiency; Intermediate Microsoft Office skills

Ability to mentor and share knowledge

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