Prior Authorization Nurse Reviewer

About the position The Prior Authorization Nurse Reviewer at Medical Mutual of Ohio is responsible for promoting effective healthcare management by conducting pre-certifications for various medical services. This role involves evaluating clinical information, collaborating with healthcare providers, and ensuring compliance with medical policies and regulations. The position allows for remote work within Ohio and requires a strong clinical utilization management background, with Medicare experience being a plus. Responsibilities • Conducts pre-certification of 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 and company policies to ensure safe and timely healthcare services. , • Promotes effective resource management by directing member care to cost-effective network providers and coordinating services at the appropriate level of care. , • Participates in interdepartmental coordination to ensure consistent delivery of quality healthcare services. , • Keeps up to date on utilization management regulations, policies, and practices, including applicable coding. , • Orients, trains, and provides guidance to junior staff if assigned as a Preceptor/Trainer. , • Performs other duties as assigned. Requirements • Graduate of a registered nursing program approved by the Ohio State Nursing Board; Bachelor's degree preferred. , • 3 years' experience as a Registered Nurse with clinical and utilization/case management experience, preferably in the health insurance industry. , • Acute care Medical/Surgical/Critical Care and ambulatory care experience preferred. , • Registered Nurse with current State of Ohio unrestricted license. , • Strong knowledge of health insurance benefits and network plan designs. , • Knowledge of HIPAA compliance and related regulations. , • Ability to apply knowledge of health plans and industry trends to achieve positive outcomes. , • Knowledge of clinical practices and efficient care delivery processes. , • Intermediate Microsoft Office skills and proficiency in navigating web-based systems. Nice-to-haves Benefits • Competitive compensation plans , • Employee bonus program , • 401(k) with company match and additional company contribution , • Excellent medical, dental, vision, and disability insurance , • Career development programs and classes , • Mentoring and coaching , • Education reimbursement up to $5K per year , • Employee discount program , • On-site wellness center , • On-site cafeteria serving hot breakfast and lunch , • Business Casual attire Apply Job!