Medicare Nurse Reviewer

About the position

The Medicare Nurse Reviewer position at Medical Mutual of Ohio involves evaluating clinical information to make authorization determinations for inpatient admissions and reviews. The role requires collaboration with physician reviewers and focuses on ensuring safe and timely transitions for patients to the appropriate level of care. This position allows for remote work flexibility.

Responsibilities

• Evaluates clinical information using established national decision support criteria, company policies, and individual patient considerations to ensure the provisions of safe, timely, and appropriate covered healthcare services.
• Independently conducts basic to complex post-acute care admissions, concurrent, and retrospective reviews, including skilled nursing facility, acute physical rehabilitation, and long-term acute care hospitals, to ensure compliance with criteria guidelines, member eligibility, benefits and contracts.
• Plans, implements, and documents discharge planning activities based on the members' specific clinical condition, health plan benefits, and optimal care delivery.
• Acts as a resource to the provider community, explaining processes for accessing the Company's website to identify network providers for next level of care and post-discharge follow-up care.
• Promotes effective resource management by directing member care to accessible cost-effective post-acute network providers and services at appropriate level of care.
• Coordinates with other Pharmacy and Care Management departments to facilitate the timely provision of covered health care services.
• Participates with designated external vendors and Assistant Medical Directors, social workers and case managers to determine potential high dollar member costs, discharge planning interventions that ensure delivery of consistent and quality health care services.
• Keeps up to date on utilization management regulations, policies and practices.
• If assigned to Preceptor/Trainer task: Orients, trains and provides guidance to more junior or less experienced staff. Supports implementation of new procedures, processes or clinical systems.
• Performs other duties as assigned.

Requirements

• Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor's degree preferred.
• 3 years as a Registered Nurse with a combination of clinical and or utilization/case management experience, preferably in the health insurance industry.
• Acute inpatient level of care in Medical/Surgical/Critical Care/ ambulatory care experience preferred.
• Registered Nurse with current State of Ohio unrestricted license.
• Intermediate Microsoft Office skills and proficiency navigating windows and web-based systems.
• Knowledge of, and the ability to apply fundamental concepts related to HIPAA compliance and related regulations.
• Knowledge of clinical practices and efficient care delivery processes.
• Ability to occasionally travel offsite for on-going training.
• Ability to occasionally work weekends and extended hours as needed.

Benefits

• 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.
• 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.
• Parental leave for eligible employees who become parents through maternity, paternity or adoption after 120 days of service.
• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year.