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UM Prospective Review, Professional, Prospective Review - RN_B

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 Req #275
Tuesday, September 10, 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—tech people, numbers people, even people people—to make health insurance more convenient, more supportive, and more personal. 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.

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.


Minimum Education:

Diploma or Associates degree in Nursing

Minimum Experience:

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. 

Required Skills:

• 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.

Preferred Skills:

• 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

Other details

  • 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