Prior Authorization 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.

Medical Mutual employees must submit their applications through MySource. This is a remote-based role, and we are currently seeking candidates located in Ohio. Job Summary: Under limited supervision, promotes effective use of, and provides appropriate resources and assistance to members managing their health care across the continuum of care. Applies evidence-based criteria and benefit interpretations to make coverage decisions. Collaborates with providers, members, and various internal departments to effectively direct care to quality cost-effective network providers at the appropriate level of care.

Conducts pre-certification of basic to complex outpatient services, surgical and diagnostic procedures, and out of network services to ensure compliance with medical policy, member eligibility, benefits, and contracts. Evaluates clinical information using established national decision support criteria, company policies, and individual patient considerations to ensure the provisions of safe, timely, and appropriately covered healthcare services. Promotes effective resource management by directing member care to accessible cost- effective network providers and coordinates 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 in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Assists Claims and/or Customer Care Departments as applicable. Keeps up to date on utilization management regulations, policies, and practices, including applicable coding. If assigned to Preceptor/Trainer task: Orients, trains, and provides guidance to more junior or less experienced staff. Supports implementation of new procedures, processes, or clinical systems. Performs other duties as assigned.