Supervisor, Acute & Post Acute Utilization Management

This is a hybrid remote role with employees expected to work onsite on designated inoffice days each week.

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.

Supervises assigned utilization staff. Ensures that utilization staff appropriately apply medical necessity guidelines in making authorization determinations for inpatient admissions, concurrent, and retrospective reviews in collaboration with physician reviewers. Oversees processes to support evidence-based discharge planning so that patients have a safe and timely transition to next level of care.

• Supervises daily operations of assigned utilization staff. Provides leadership and change management to promote staff retention, drive operational efficiency and effectiveness, and improve clinical and quality outcomes. Encourages the desire to learn by fostering an environment of transparency and support. Sets and manages expectations for the team by defining clear goals and objectives and providing quarterly performance reports. Communicates with all levels, tailoring messaging to audience.
  
  Presents a unified leadership voice that reflects the Company's goals and values.
• Ensures appropriate use of staff resources to facilitate accurate and timely utilization management decisions and discharge planning in collaboration with Providers and the Company's interdisciplinary team of Physicians, Case Managers, Social Workers, Pharmacists, Behavioral Health team, etc., by facilitating internal huddles and external care conferences.
• Supports staff onboarding; oversees development of meaningful training curriculum and plan, delivers effective coaching and feedback and builds professional development into fabric of the team. Continues to develop current knowledge of approved criteria, evidence-based practice and standards of care to support the delivery of high quality, efficient and timely utilization management decisions and discharge planning as measured by audits.
• Ensures that utilization staff appropriately gather the requisite data and information to enter authorizations. Tracks, trends and monitors the accuracy of data and timeliness of authorization decisions. Monitors designated reports to ensure internal controls are effective. Drives towards solutions that support departmental goals.
• Evaluates individual and team performance against established targets; motivates staff to meet departmental and organizational goals related to utilization, cost, quality and productivity targets; accountable for the team's overall results as well as driving employee engagement as measured by employment surveys.
• Assists Manager in coordinating and facilitating system processes with providers, partners, vendors, and subcontractors as necessary.
• Ensures compliance with company policy and procedure, as well as state and federal rules and regulations and accreditation standards.
• Performs other duties as assigned.

• Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor of Science in Nursing or Healthcare Administration preferred.
• 7 years or more progressive experience as a Registered Nurse (RN) in health insurance utilization review or case management, or equivalent relevant RN experience in a clinical practice.
• Relevant experience leading teams or projects (formally or informally).

• Registered Nurse with current Ohio unrestricted license required.
• Lean Six Sigma Yellow Belt preferred.

• Intermediate Microsoft Office skills and proficiency navigating windows and web-based systems.
• Knowledge of medical terminology/coding and managed care processes.
• Knowledge of and the ability to apply fundamental concepts related to HIPAA compliance and related regulations.
• Knowledge of disease continuums, expected patient outcomes and community services available.
• Knowledge of clinical claim management including ICD 10, CPT and HCPCS code.
• Knowledge of health insurance benefits and network plan designs.
• Knowledge of care delivery systems and continuum of acute through post-acute care.
• Ability to prioritize multiple projects and initiatives and problem solve in a fast-paced environment.
• Ability to interpret data for root cause analysis and apply continuous process improvement methodologies.
• Knowledge of Lean Six Sigma principles preferred.
• Ability to supervise teams and facilitate change.

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:

• We will provide the equipment you…