Supervisor, Clinical Operations

Medical Mutual•Cleveland, OH

8h•Hybrid

About The Position

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. This is a hybrid role requiring 3 days per week on-site in our Brooklyn, Ohio office.

Requirements

Graduate of a registered nursing program approved by the Ohio State Nursing Board.
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)
Registered Nurse with current State of Ohio unrestricted license.
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.

Nice To Haves

Bachelor’s Degree preferred.

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.

Benefits

Laptop, monitors, keyboard, mouse and headset provided.
Access to on-site fitness centers or gym membership reimbursement.
On-site cafeteria.
Discounts at many places in and around town.
Opportunity to earn cash rewards for shopping with customers.
Business casual attire, including jeans.
Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Medical, dental, vision, life and disability insurance.
Access to an Employee Assistance Program.
Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
Parental leave for eligible employees who become parents through maternity, paternity or adoption.
Career development programs and classes.
Mentoring and coaching.
Tuition reimbursement up to $5,250 per year.
Diverse, inclusive and welcoming culture with Business Resource Groups.