[Hiring] Professional, Prospective Review RN @MVP Health Care

Join Us in Shaping the Future of Health Care At MVP Health Care, we’re on a mission to create a healthier future for everyone. That means embracing innovation, championing equity, and continuously improving how we serve our communities. Our team is powered by people who are curious, humble, and committed to making a difference—every interaction, every day. We’ve been putting people first for over 40 years, offering high-quality health plans across New York and Vermont and partnering with forward-thinking organizations to deliver more personalized, equitable, and accessible care. As a not-for-profit, we invest in what matters most: our customers, our communities, and our team. What’s in it for you:

• Growth opportunities to uplevel your career
• A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team
• Competitive compensation and comprehensive benefits focused on well-being
• An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District, one of the Best Companies to Work For in New York, and an Inclusive Workplace.

You’ll contribute to our humble pursuit of excellence by bringing curiosity to spark innovation, humility to collaborate as a team, and a deep commitment to being the difference for our customers. Your role will reflect our shared goal of enhancing health care delivery and building healthier, more vibrant communities. About the Opportunity As a Professional, Prospective Review in Health Management - UM Prospective Review, you will play a crucial role in ensuring the quality and efficiency of our prospective review process. You will work closely with the healthcare team to review and assess the appropriateness of medical services, treatments and high dollar medical equipment. This is an exciting opportunity to contribute to the improvement of patient care and outcomes. What You’ll Do

• Conduct comprehensive reviews of medical records and treatment plans to determine if the requested services are appropriate based on established guidelines and medical criteria across multiple lines of business.
• Utilize your clinical expertise to evaluate medical necessity and collaborate with MVP Medical Directors to determine the effectiveness of proposed treatments/equipment.
• Document clinical summations, recommendations and send appropriate correspondences accurately and within regulatory timeframes.
• Communicate with healthcare providers and members to collect pertinent information, discuss review outcomes and provide appropriate referrals within MVP.
• Remain up to date with industry standards and guidelines, complete required competency training and proficiency examinations to ensure compliance and best practice.
• Participate in team meetings and training sessions to enhance your knowledge and skills.
• Contribute to process improvement initiatives to streamline the prospective review process.
• Other duties as assigned by leadership.

Skills and Experience

• Education, Licensures, & Certifications
• Current RN (NY or VT)
• Years of Experience (Required & Preferred)
• Minimum of 3-5 years clinical experience required
• Case management certification preferred
• Required Job Skills
• Able to manage multiple tasks in a fast-paced environment.
• Strong clinical knowledge, critical thinking skills and understanding of medical terminology, procedures, concepts.
• Ability to work independently to analyze complex medical information.
• Effective communication skills, both written and verbal.
• Ability to work independently and collaboratively in a team environment.
• Proficiency in using computer systems and software for documentation, data entry and day-to-day work functions.
• Preferred Job Skills
• Prior Utilization review experience
• Knowledge of Government Insurance Programs (Medicare, Medicaid)

Working Conditions Secure, Quiet area for Desk/Computer to maintain HIPPA compliance Travel Requirements Potential for travel to regional offices Worksite Designation

• Virtual based out of Schenectady NY

Pay Transparency MVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role. We do not request current or historical salary information from candidates. $69,383.00-$92,279.00 MVP's Inclusion Statement At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration. MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam-era or special disabled Veteran or other legally protected classifications. To support a safe, drug-free workplace, pre-employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team at [email protected]. Apply tot his job Apply To this Job