Manager, Member & Provider Appeals Job Listing at Medical Mutual in Brooklyn, OH (Job ID 593e2de9-394f-44e0-aade-8d67a992f169)

Description

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.

Manages staff and end‑to‑end operations for member and provider appeals and claim review. Ensures compliance with government regulations, accreditation standards, performance guarantees, and internal policies and procedures. Leads the implementation of procedural and system enhancements to strengthen operational efficiency. Establishes performance metrics, drives accountability, and promotes consistency across multiple locations and departments performing policy and administrative functions. Oversees service‑quality studies and reporting, identifying opportunities to improve both service delivery and operational effectiveness. Collaborates across the organization to support corporate goals and align business processes enterprise‑wide.

Responsibilities:

• Manages the day to day operation of the Appeal & Claim Review Ensures workflow and escalated issues are handled and resolved. Monitors the effectiveness of programs and procedures. Identifies operational inefficiencies and recommends improvements. Develops, tests, and implements system and process changes. Assists with coordinating and facilitating processes and initiatives.
• Analyzes root cause of appeals. Tracks and trends issues to identify opportunities for improvement. Proactively identifies risks. Leads and/or participates in cross-functional teams and committees to ensure comprehensive and coordinated efforts to remediate issues and facilitate process improvements throughout the organization. Reviews production and quality data to ensure accuracy and consistent application of policies and procedures.
• Maintains strong subject matter expertise in state and federal regulations and contractual obligations governing appeals. Ensures operational compliance with regulatory requirements and company policies.   Ensures accurate timely reporting to meet internal and external reporting requirements.
• Oversees staffing, performance management, while motivating and coaching staff to achieve regulatory compliance and meet internal qualitative and quantitative productivity guidelines. Monitors work inventory and staff productivity and adjusts assignment to ensure productivy and compliance standards are met
• Participates/contributes in accreditation compliance efforts including reporting, quality improvement studies and site visits. Contributes responses regarding appeal process matters initiated through the Request for Proposal process. Responsible for data validation reporting and analysis and oversite for STAR measures.
• Ensures timely and accurate written communication to providers, members, and regulatory entities regarding review status. Partners with the provider community, participates in joint operating committees, and project workgroups. Collaborates with providers, members, and across the organization to ensure that members are getting the appropriate care at the most appropriate time.
• Performs other duties as assigned.

Qualifications

Education and Experience

• The position requires a graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor's degree preferred.
• 8 years of progressive experience in health plan operations, appeals, clinical review, or related fields, including a minimum of 3 years in leadership.
• Experience with member/provider complaint resolution, and health insurance regulatory compliance preferred.
• Clinical appeal and claim review experience preferred.

Professional Certification(s)

• Registered Nurse (Ohio) required

Technical Skills and Knowledge

• Strong working knowledge of state and federal appeals regulations.
• Comprehensive understanding of operational process flows, including process‑flow analysis and quality/process improvement methods.
• Comprehensive knowledge of medical terminology, claims adjudication, UM processes, and applicable coding (ICD‑10, CPT, HCPCS, revenue codes) and benefits interpretation
• Intermediate to advanced Microsoft Office and health insurance operations systems skills.
• Ability to formulate quality improvement initiatives, policies and procedures and management and regulatory reports.
• Ability to lead for optimal effectiveness, facilitate change, and produce results

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:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits and Compensation:

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year, the IRS maximum.
• Diverse, inclusive and welcoming culture with Business Resource Groups.

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.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.