Note, this is a fully remote opportunity; Ohio candidates that reside in the areas of Brooklyn/Cleveland, Toledo, Columbus and Cincinnati.

Provides clinical expertise to promote the delivery of high quality, cost effective, (member centric) medical care. Contributes to the achievement of clinical excellence; quality ratings improvement, appropriate inpatient and outpatient utilization, affordability, compliance, growth and focused improvement and that initiatives are consistently implemented and successfully executed to achieve goals.

Responsibilities

• Provides clinical expertise to the utilization review process and determinations.
• Provides pre-determination reviews and reviews of claims determinations, providing clinical, coding and reimbursement expertise.
• Ensures compliance with clinical goals through monitoring of care management performance.
• Ensures the appropriate and most cost effective medical care is received.
• Recommends changes and enhancements to current managed care, review guidelines, and clinical criteria based on clinical knowledge of health care delivery systems, utilization methods, reimbursement methods and treatment protocols.
• Assists in development and interpretation of medical policy, including medical necessity criteria, clinical practice guidelines, and new technology assessments.
• Provides guidance to case management team in the coordination of quality care.
• Performs other duties as assigned.

Qualifications

Education and Experience

• MD or DO from an accredited medical school with an active, unrestricted (state) license to practice medicine in United States.
• Minimum of 5 years of established (clinical) care practice experience required.
• Physician reviewer experience in the insurance industry preferred.

Professional Certifications

• Board Certification, in nationally recognized specialty (ABMS or AOA) is required.
• Active unrestricted license to practice medicine in U.S.

Technical Skills and Knowledge

• Foundational windows based computer skills, including typing, word processing, presentation, and internet research skills.
• Strong understanding of integration of evidence-based medicine and managed care principles.

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:

• Top Workplace in Northeast Ohio. Year after year we've received this recognition!
• On-site wellness center at most locations. Enjoy personal trainers, locker room, weight room, elliptical machines, and a variety of classes!
• On-site cafeteria serving hot breakfast and lunch, at most locations. Choices ranging from salad bar, made to order, hot and cold sandwiches, or a variety of entrees cooked fresh daily. Convenience store at most locations
• Employee discount program. Discounts at many places in and around town, just for being a Medical Mutual team member
• Business Casual attire

Excellent Benefits and Compensation:

• Competitive compensation plans
• Employee bonus program
• 401(k) with company match and an additional company contribution
• Excellent medical, dental, vision, and disability insurance

An Investment in You:

• Career development programs and classes
• Mentoring and coaching to help you advance
• Education reimbursement up to $5K per year

About Medical Mutual:

We strive to create peace of mind. Our customers can trust us to do things right and to help them get value from their health plan. We're the largest health insurer in Ohio and for over 85 years, we've been serving our members and the Ohio communities where they live and work. Medical Mutual is a Top Place to Work in Northeast Ohio with exceptional career opportunities that offer challenge, growth and a great work/life balance. We want talented, innovative, and driven people to help us continue to be the best health insurance choice of Ohioans and help make Ohio the best it can be! Our headquarter building is located in Brooklyn, OH and we have multiple offices throughout the state. Join us at one near you!

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.