UM Prospective Review, Professional, Prospective Review - RN_B
Status: Full-time, Exempt: Yes
Reviews and evaluates provider requests for authorization of services: prior to initiation of care, for continuation/ extension of care or after care has been rendered. Determinations of medical necessity and appropriateness of care are based on predetermined criteria and/or guidelines. Ensures that MVP benefits and policies are properly interpreted, and that care is rendered in the most appropriate site of service with a focus on quality care and cost-efficient outcomes. Assures timely responses to provider and member requests for services per department standards. Performs other duties as assigned.
Diploma or Associates degree in Nursing
RN or LPN with 3 years of UM experience preferred.
2 years of direct interaction with health care providers in an acute hospital or office setting is required.
• Must display strong verbal communication skills and the ability to deal with providers, members and staff tactfully and
• Good organizational skills and the ability to set priorities.
• Excellent problem solving and analytical skills.
• Strong basic computer and keyboard skills
• Internet skills helpful to enable individual to research guidelines.
• Knowledge of ICD-9, CPT coding strongly preferred
• Working knowledge of managed care concepts and practices preferred.
• Experience with standard utilization review techniques and protocols as well as knowledge of alternate health care delivery
options strongly preferred.
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 firstname.lastname@example.org.
- Job Family Medical Management/Clinical
- Pay Type Salary
- Headquarters Office, Schenectady, New York, United States of America
- Rochester Office, Rochester, New York, United States of America
- Tarrytown Office, Tarrytown, New York, United States of America