Professional, Prospective Review RN

MVP Health Care • Schenectady, NY

11d • $69,383 - $92,279 • Remote

About The Position

As a Professional, Prospective Review in Health Management 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.

Requirements

• Current RN (NY or VT)
• Minimum of 3-5 years clinical experience required
• 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.

Nice To Haves

• Case management certification preferred
• Prior Utilization review experience
• Knowledge of Government Insurance Programs (Medicare, Medicaid)

Responsibilities

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 501-1,000 employees