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Professional, Prospective Review

Headquarters Office, Schenectady, New York, United States of America Req #263
Thursday, August 29, 2019
Be a part of the transformation at MVP Health Care®. MVP Health Care is a nationally-recognized, regional not-for-profit health insurer. We care for more than 700,000 members across New York and Vermont and are powered by the ideas and energy of more than 1,700 employees. We employ talented people with  diverse  backgrounds and experience  to make health insurance more personal. Our clinical staff works with doctors, hospitals, pharmacies, and other health care professionals are dedicated to improving the delivery of health care: with better communication, better sharing of information, and ultimately, better results for our members. If you’re ready to join a thriving, mission-driven company where you can create your own opportunities—it’s time to make a healthy career move to MVP.
Performs review of Durable Medical Equipment, Orthotics, prosthetics and other specialty equipment and related services for medical necessity. Applies established Medicare Guidelines or Benefit Interpretation criteria and standards. Responsible for collecting and interpreting medical information for appropriateness of care. Communicates determinations to all parties involved, verbally and in writing, including scope of authorization. Facilitates deployment of services and conducts retrospective review of all services when necessary. Reviews problem and complex cases with leaders. Communicates effectively with Senior Medical Leaders, physicians, individual providers and other departments for ongoing coordination of services, including hospital discharges. Negotiates rates and discounts for non-contracted vendor when necessary. Knows and interprets the MVP contracts, riders, policies and procedures. Complies cost savings reports, attends in-services and interdepartmental meetings. Develops and maintains positive relationships with physicians, facilities and vendors. Identifies trends, new technology and policy needs. Performs other duties as assigned.

Minimum Education: LPN or RN with 1-3 years clinical experience

Minimum Experience: Minimum of 1 - 3 years Utilization Management experience is preferred Utilization Management experience in a pre-paid healthcare setting is preferred

Required Skills:
• Previous experience with durable medical equipment and/or knowledge of HCPCS Coding is preferred.
• Able to manage multiple tasks in a fast-paced environment.
• Independent thought process; oriented toward problem solving;
• Strong interpersonal and communication skills.
• Excellent computer skills
MVP Health Care is an Affirmative Action/Equal Opportunity Employer (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at

Other details

  • Job Family Medical Management/Clinical
  • Pay Type Salary
  • Headquarters Office, Schenectady, New York, United States of America