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Director, Utilization Management & Operational Integrity
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Director, Utilization Management & Operational Integrity

Medical Mutual of Ohio -
Cleveland, OH

Apply Now

Job Details

11 days ago

Benefits

Health savings account
Disability insurance
Health insurance
Dental insurance
Tuition reimbursement
Paid time off
Parental leave
Employee assistance program
Vision insurance
401(k) matching
Gym membership

Qualifications

RN License
Managed care organization experience
Utilization management
Bachelor of Science in Nursing
Bachelor's degree in nursing
Clinical confidentiality policies
Project leadership

Full Job Description

Medical Mutual employees must submit their applications through MySource.

Note: This is a hybrid role based in Brooklyn, OH, requiring four days per week on-site.

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.

Job Summary:

Directs operations related to Commercial and Medicare acute and post-acute care services to advance evidence-based policies, protocols, and practices to ensure efficient use of health care services and adherence to corporate and regulatory standards. Directs education, training, and auditing of all clinical services and operational staff.

Responsibilities:

Analyzes trends and identifies/implements departmental initiatives based upon data provided through the reporting of production, quality, financial and audit data.
Optimizes processes and workflows to achieve successful quality outcomes and benefit maximization.
Leads the oversight and management of key performance indicators and monitors and tracks to independently identify over/under utilization patterns and/or deviation from expected results.
Develops and implements utilization targets and drives accountability to benchmark metrics for staff productivity and membership management
Oversees the onboarding, education, training, and ongoing monitoring of all Clinical Services & Operations staff, ensuring appropriate decision-making, application of criteria, documentation, and adherence to all regulatory requirements across all lines of business.
Oversees the recruiting, performance, development and mentoring of staff.
Ensures that team members are clinically competent and adequately trained to apply medical necessity criteria.
Provides leadership and support to managers and supervisors.
Ensures monitoring and tracking tools are in place to adequately link and assess production and quality driven work products and outcomes to individual performers.
Leads talent management activities to develop and cultivate future leaders.
Oversees the implementation of processes and systems to improve the efficiency and effectiveness of utilization management for inpatient services.
Develops effective relationships with key health systems to improve communication, efficiency and effectiveness of utilization review process including leading clinical meetings to facilitate relationship building and identifying opportunities to advance access to EMRs/Portals.
Serves as the subject matter expert liaison for acute and post-acute service and/or leader on cross-functional teams.
Initiates cross functional/departmental discussions and initiatives to remove barriers and improve communications and workflows.
Develops formal policies, procedures and workflows that effectively guide quality of work.
Performs other duties as assigned.

Qualifications:

Education and Experience:

Bachelor of Science in Nursing required. Master’s degree preferred.
8 years progressive experience in managed care utilization management, 5 years of which are in a leadership or project management capacity.
Experience with process improvement techniques preferred.

Professional Certification(s):

Registered Nurse with current unrestricted license in state of residency required.
Ability to obtain Ohio RN or Multi-state RN Compact License within 60 days of date of hire.
Ability to obtain additional RN licensure for multi-state member management within 90 days of hire.

Technical Skills and Knowledge:

Comprehensive knowledge of NCQA accreditation standards and CMS regulations, HIPAA compliance and the ability to apply advanced concepts to Company operations.
Strong computer skills (Microsoft Office, including Outlook, Excel, PowerPoint, Word).
Demonstrated success with improving achieving productivity for authorization requests.
Strong demonstrated communication and presentation skills.
Strong knowledge of clinical claim management including ICD 10, CPT and HCPCS codes.
Strong knowledge of health insurance benefits and network plan designs.
Abiltiy to apply knowledge of health plans and industry trends to achieve positive outcomes.
Thorough understanding of clinical knowledge, members’ specific health plan benefits, and efficient care delivery processes.
Knowledge of care delivery systems and continuum of acute through post-acute care.

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.

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

#LI-SC1 #LI-HYBRID

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.

Apply Now

Refine Your Search

icd program director jobs

Director, Utilization Management & Operational Integrity

Finance Director

Dialysis Clinical Manager Registered Nurse - RN

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Executive Director of School Based Early Childhood Day Treatment

Sr Principal Engineer Systems

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Staff Systems Engineer - Execution Lead

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Principal Weapons Integration Avionics Hardware Engineer

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Staff Systems Engineer

Principal Software Development Analyst – SW App Test Anal (SA) (26-251)

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Utilization Review Specialist

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Staff Systems Engineer - Execution Lead

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