Claim analyst Jobs in Columbus oh

Note : This position allows you the flexibility to work at home. We are looking for applicants that have a strong clinical utilization management background. Medicare experience is a plus.

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.

Working under limited supervision, evaluates clinical information using evidence-based guidelines, company policies and individual patient considerations to ensure the provisions of safe, timely and appropriate healthcare services. Promotes effective use of resources and provides assistance to members in managing their health care across the continuum of care.

Responsibilities

• Independently evaluates basic to complex medical claims and / or appeal cases and associated records by applying clinical, regulatory, and policy and procedures knowledge and experience to assess the appropriateness of service provided, length of stay and level of care
• Extrapolates and summarizes medical information for physician review or other external review
• Generates appropriate written status of review to providers, members, and regulatory entities advising of status
• Acts as a resource to the provider community, explaining processes for accessing health plan to perform clinical review, identifying appropriate community resources, or otherwise interacting with health plan programs and services
• Orients, trains, and provides guidance to more junior or less experienced staff. Facilitates work assignments
• Collaborates with providers, members, and various internal departments to ensure that members are getting appropriate care at the most appropriate time
• Keeps up to date on utilization management regulations, policies, and practices, including applicable coding
• Performs other duties as assigned

Qualifications

Education and Experience :

Professional Certification :

Technical Skills and Knowledge :

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 :

Excellent Benefits and Compensation :

An Investment in You :

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.

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.

LI-REMOTE