Manager, Member & Provider Appeals

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.

Note:

This is a hybrid role requiring 4 days per week on-site in our Brooklyn, OH office. Seeking applicants that reside within a 50-mile radius of the Brooklyn, OH office.

Manages staff and end‑to‑end operations for member and provider appeals and claim review. Ensures compliance with government regulations, accreditation standards, performance guarantees, and internal policies and procedures. Leads the implementation of procedural and system enhancements to strengthen operational efficiency. Establishes performance metrics, drives accountability, and promotes consistency across multiple locations and departments performing policy and administrative functions. Oversees service‑quality studies and reporting, identifying opportunities to improve both service delivery and operational effectiveness.

Collaborates across the organization to support corporate goals and align business processes enterprise‑wide.

• Manages the day‑to‑day operation of the Appeal & Claim Review. Ensures workflow and escalated issues are handled and resolved. Monitors the effectiveness of programs and procedures. Identifies operational inefficiencies and recommends improvements. Develops, tests, and implements system and process changes. Assists with coordinating and facilitating processes and initiatives.
• Analyzes root cause of appeals. Tracks and trends issues to identify opportunities for improvement. Proactively identifies risks. Leads and/or participates in cross‑functional teams and committees to ensure comprehensive and coordinated efforts to remediate issues and facilitate process improvements throughout the organization. Reviews production and quality data to ensure accuracy and consistent application of policies and procedures.
• Maintains strong subject‑matter expertise in state and federal regulations and contractual obligations governing appeals. Ensures operational compliance with regulatory requirements and company policies. Ensures accurate timely reporting to meet internal and external reporting requirements.
• Oversees staffing, performance management, while motivating and coaching staff to achieve regulatory compliance and meet internal qualitative and quantitative productivity guidelines. Monitors work inventory and staff productivity and adjusts assignment to ensure productivity and compliance standards are met.
• Participates/contributes in accreditation compliance efforts including reporting, quality improvement studies and site visits. Contributes responses regarding appeal process matters initiated through the Request for Proposal process. Responsible for data validation reporting and analysis and oversight for STAR measures.
• Ensures timely and accurate written communication to providers, members, and regulatory entities regarding review status. Partners with the provider community, participates in joint operating committees, and project work groups. Collaborates with providers, members, and across the organization to ensure that members are getting the appropriate care at the most appropriate time.
• Performs other duties as assigned.

• The position requires a graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor's degree preferred.
• 8 years of progressive experience in health plan operations, appeals, clinical review, or related fields, including a minimum of 3 years in leadership.
• Experience with member/provider complaint resolution, and health insurance regulatory compliance preferred.
• Clinical appeal and claim review experience preferred.

• Registered Nurse (Ohio) required

• Strong working knowledge of state and federal appeals regulations.
• Comprehensive understanding of…