Professional, Sub-Acute RN UM Reviewer - Medicare

MVP Health Care • Schenectady, NY

97d

About The Position

This position involves conducting utilization reviews for sub-acute Medicare cases, ensuring that services provided meet established medical necessity criteria and guidelines. The role requires collaboration with various healthcare providers and facilities to support discharge planning and continuity of care. The successful candidate will be responsible for maintaining compliance with regulatory standards and participating in quality improvement initiatives.

Requirements

• Current and unrestricted NY & VT RN licensure
• Associate or bachelor's degree in nursing (BSN preferred)
• Minimum 3 years of clinical nursing experience
• At least 2 years of experience in utilization management of sub-acute Medicare reviews
• Experience with Medicare guidelines and documentation standards preferred
• Strong knowledge of sub-acute care, rehabilitation, and skilled nursing services
• Proficiency in interpreting medical records and applying medical necessity criteria
• Understanding of discharge planning process and transitional care needs
• Excellent communication, critical thinking, and organizational skills.
• Experience with electronic medical record (EMR) systems and UM platforms.
• Familiarity with CMS regulations and appeals processes.
• Ability to work independently and manage multiple priorities.
• Curiosity to foster innovation and pave the way for growth
• Humility to play as a team
• Commitment to being the difference for our customers in every interaction

Responsibilities

• Conduct timely and accurate utilization reviews for sub-acute Medicare cases.
• Evaluate medical necessity, level of care, and appropriateness of services based on established criteria and guidelines.
• Support and assess discharge planning efforts to ensure continuity of care and appropriate post-acute services.
• Collaborate with providers, facilities, and interdisciplinary teams to ensure optimal patient care and resource utilization.
• Document review outcomes and maintain compliance with regulatory and organizational standards.
• Participate in audits, quality improvement initiatives, and training sessions.
• Maintain current knowledge of Medicare regulations and UM best practices.
• Other duties as assigned by leadership.

What This Job Offers

• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree