What are the responsibilities and job description for the Medical Drug Management Nurse Reviewer position at Medical Mutual?
This is a remote opportunity in Ohio. Note, q uarterly 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 1.6 million Ohioans 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.
Qualifications
Qualifications
Education and Experience
Professional Certification
Technical Skills and Knowledge
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 :
Excellent Benefits and Compensation :
An Investment in You :
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.
Salary : $5,250
