Quality Safety Review Nurse Job Listing at Medical Mutual in OH (Job ID 2400293)

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.

Works with management, external vendors, and Information Systems to define, develop, test, audit and implement new business systems and processes. Identifies and solves production issues, which may require system changes.  Communicates system changes to users and Training.

Responsibilities

• Reviews and investigates routine to moderately complex assigned cases, which may include reviewing multiple high-volume medical records, speaking with members or providers as needed, corresponding with various business areas and individuals including medical directors or the Chief Medical Officer.
• Determines appropriate medical records needed to thoroughly investigate case. Researches relevant clinical practice guidelines and evaluates case findings against evidence-based practice. Draws upon clinical experience to determine disposition of a case.  Applies appropriate quality level and coding in tracking system.  Under guidance and/or review of more senior levels, prepares escalated case files for physician review.
• Manages individual case inventory to assure timely resolution for grievances, complaints and quality cases per policy/NCQA/CMS guidelines.
• Collaborates with Appeals & Grievances, Population Health, Provider Contracting, Customer Care and/or Clinical Quality & Health Services departments to resolve cases.
• Sends appropriate letters and documents in clinical system.
• Assists in transforming data related to case trends into comprehensive narrative reports that includes methodology, results compared to benchmark or goal, quantitative and qualitative analyses, barriers, opportunities, and recommendations.
• Develops and implements action plan. Assists in organizing and leading cross-functional teams. Under guidance and/or review of more senior levels, applies process and performance improvement tools and techniques to improve quality/safety.
• Reports verbally in-person at committees or staff meetings.
• Researches and maintains library of clinical practice guidelines for departmental use.
• Contributes to writing and updating of departmental policies and procedures.
• Assists in maintaining template member and provider letters. 
• Supports team/management in peer review processes and departmental administrative functions including committees.
• Monitors reports, drafts data requests as needed and meets with HIMA.
• Reviews related content in provider manual.
• Performs other duties as assigned.

Qualifications

Quality Safety Review Nurse

Education and Experience

• Graduate of a registered nursing program approved by the Ohio State Nursing Board.  Bachelor of Science in Nursing preferred.  Master's degree in related field a plus.
• 3 years clinical experience as a Registered Nurse, preferably in a health plan.
• Preferred experience with participation in quality improvement team/projects.

Professional Certification(s)

• Registered Nurse with current State of Ohio unrestricted license.

Technical Skills and Knowledge

• Knowledge of principles/practices in investigating and resolving member complaints, grievances and/or quality of care and safety issues.
• Ability to conduct online research for updates on clinical practice guidelines. 
• Knowledge of process and performance improvement methods and tools.
• Intermediate Microsoft Office skills – (Word, PowerPoint, and Excel).
• Ability to organize work by priority.
• Demonstrated project management skills.

Sr Quality Safety Review Nurse

Education and Experience

• Graduate of a registered nursing program approved by the Ohio State Nursing Board.  Bachelor of Science in Nursing preferred.  Master's degree in related field a plus.
• 5 years clinical experience as a Registered Nurse, including 1 year in a clinical quality review nurse role, care management, utilization management, medical case review or similar role.
• Prior experience leading quality improvement teams.

Professional Certification(s)

• Registered Nurse with current State of Ohio unrestricted license.
• Six Sigma, or other nationally recognized professional association such as Certified Professional in Healthcare Quality (CPHQ), CCM, CPPS, is preferred.

Technical Skills and Knowledge

• Strong knowledge of principles/practices in investigating and resolving member complaints, grievances and/or quality of care and safety issues.
• Ability to conduct online research for updates on clinical practice guidelines. 
• Strong knowledge of process and performance improvement methods and tools.
• Knowledge of Plan Do Study Act (PDSA, Lean).
• Intermediate to advanced Microsoft Office skills – (Word, PowerPoint and Excel).
• Comprehensive knowledge of related NCQA standards on complaints-member and provider, quality improvement and CMS regulations for quality of care grievances.
• Ability to organize work by priority
• Demonstrated project management skills with the ability to handle multiple, concurrent projects through to completion.

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.