Acute & Post Acute Nurse Reviewer II

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.

Under limited supervision, applies medical necessity guidelines in making authorization determinations for inpatient admissions, concurrent, and retrospective reviews in collaboration with physician reviewers. Applies evidence-based discharge planning so that patients have a safe and timely transition to next appropriate level of care.

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 emergency and acute care admissions, concurrent, and retrospective reviews of inpatient admissions, 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 Independently remains current on utilization management regulations, policies, and practices. 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. Performs other duties as assigned.