Medical Drug Management Nurse Reviewer

DescriptionThis is a remote opportunity in Ohio. Note, quarterly on-site requirement in Brooklyn, Ohio. Ohio candidates 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.Manages utilization of healthcare services to ensure the provision of safe, timely, appropriate, and necessary covered medical drugs and associated services/procedures to members. Promotes effective resource management by directing member care to accessible cost-effective network providers and services at the appropriate level of care. Facilitates continuity of care across healthcare settings.Responsibilities• Determines appropriateness of services and procedures. Manages initial, concurrent, and retrospective review of cases, including appeals, through evaluation of clinical information using established national decision support criteria, Company policies, individual patient considerations, and clinical judgment. Refers cases that are complex or outside the established criteria and guidelines to the Clinical Pharmacist and/or Assistant Medical Director.• Evaluates and direct members to services at the appropriate level of care (i.e., hospital outpatient, provider office or home infusion as part of prior approval and claim appeals.• Facilitates members and providers to ensure continuity of care across healthcare settings. Assists member with locating in network services.• 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.• 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.• Maintains a working knowledge of applicable accreditation and regulatory requirements. Participates in continuing nursing, pharmacy, and medical education classes to assist in understanding new treatment concepts and their incorporation into current practice.• Performs other duties as assigned.QualificationsQualificationsEducation and Experience• Graduate of a registered nursing program approved by the Ohio State Nursing Board.• 3 years as a Registered Nurse with a combination of clinical and utilization/case management experience in pharmacy, medical/surgical, or psychiatric, preferably in the health insurance industry.Professional Certification• Registered Nurse with current State of Ohio unrestricted license.Technical Skills and Knowledge• Knowledge of medical/pharmacy terminology/coding and managed care processes. Understanding of the medical review (i.e., prior authorization) process and managed care principles.• Knowledge of care delivery systems and continuum of acute through post-acute care.• Knowledge of National Committee for Quality Assurance (NCQA) accreditation standards.• Strong knowledge of clinical claim management including ICD 10, CPT and HCPCS codes.• Strong knowledge of health insurance benefits and network plan designs.• Knowledge of and the ability to apply fundamental concepts related to HIPAA compliance and related regulations.• Ability to apply knowledge of health plans and industry trends to achieve positive outcomes.• Intermediate Microsoft Office skills and proficiency navigating windows and web-based systems.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.• 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.At Medical Mutual and its family of companies 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-OhioJob: 7 - General StaffOrganization: PharmacySchedule: RegularShift: StandardEmployee Status: Individual ContributorJob Type: Full-timeJob Level: Day JobJob Posting: Aug 20, 2024, 6:45:20 PM