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Professional, Concurrent Review
3 months ago
Over 35 years strong and fueled by 1,700 smart, passionate employees across New York state and Vermont, MVP is full of opportunities to grow. We are a nationally recognized, award-winning leader for a reason. The beating heart of our company is a wide range of employees from a diverse set of backgrounds-tech people, numbers people, even people people-working together to make health insurance better. If you are ready to join a thriving, mission-driven company where you can create your own opportunities and make a positive difference-it's time to make a healthy career move to MVP
Status: Full Time, Exempt
This position tracks and influences the services provided to MVP customers as they move through the continuum of care. The Concurrent Review RN is responsible for evaluating the medical necessity of medical treatments and services and coordinating care for customers to ensure all physical, developmental, and behavioral health needs are being met. This position can be worked remotely/virtually from within New York or Vermont with the potential to travel.
Essential Functions:
- Implements the operational functions of the MVP Utilization Management program.
- Reviews inpatient medical records against established criteria and standards to determine medical appropriateness and level of care assignment.
- Reviews individual claims requiring clinical interpretation and judgment.
- Tracks on a regular basis the required care of individual members and advises providers of desired delivery options such as equipment vendors and home care agents.
- Collects and reviews care plans and progress reports to justify extension of service authorization.
- Evaluates the physical health and any co-morbid developmental or behavioral health disorders to identify, plan, implement, evaluate, and coordinate options and services necessary to meet an individual's essential health needs.
- Reviews complex cases with individual providers, in MVP clinical/integrated rounds, with MVP Medical Directors, and/or with MVP Leadership.
- Knows and interprets the MVP contract, riders, policies, and procedures.
- Performs other duties as assigned.
Minimum Education:
- RN with current/active New York State licensure required.
- BS in Nursing or Health Management is preferred.
- 3+ years strong clinical background required.
- Minimum of 1 year UM experience is preferred.
- Familiarity with National Criteria Standards is preferred.
- Med/Surg and Behavioral Health experience is preferred.
- Excellent verbal and written communication abilities.
- Independent thought process; oriented toward probing/problem solving.
- Strong computer skills including working knowledge of Word, Windows based applications, typing and internet access.
MVP Health Care is a nationally recognized, not-for-profit health insurer caring for members in New York and Vermont. Committed to the complete well-being of our members and the communities we serve, MVP makes health insurance more convenient, more supportive, and more personal. We are powered by the ideas and energy of more than 1,700 diverse employees from all backgrounds, committed to having a positive impact on the health and wellness of everyone we serve.
At MVP, we are committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. Specific employment offers and associated compensation will be made individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role.
In addition, we offer a comprehensive benefits package that includes:
- Considerable paid time away from work including PTO (Paid Time Off), sick time, service time off, paid holidays, and floating holidays, allowing you to take time off when it suits you best.
- Competitive 401(k) employer matching and profit-sharing program to help you save for your retirement.
- Low premium health benefits including medical, dental, and vision coverage to support your well-being and that of your family.
- Life insurance and disability coverage to ensure financial security for you and your dependents.
- An array of optional benefit plans such as accident insurance and specified disease coverage to protect you from the unexpected.
- Full tuition reimbursement (up to the IRS limit) for approved courses and programs that support continuous learning.
- A best-in-class employee Well-Being program to support all dimensions of your health and wellness.
MVP Health Care is an Affirmative Action/ Equal Employment Opportunity (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), and the Know your Rights 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
Please apply and learn more - including how you may become a proud member of our team.
Other details
- Job Family Medical Management/Clinical
- Pay Type Salary
- Min Hiring Rate $56,200.00
- Max Hiring Rate $110,319.00
