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UM Prospective Review, Professional, Prospective Review - LPN

Headquarters Office, 625 State Street, Schenectady, New York, United States of America Req #450
Thursday, January 23, 2020
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
Performs review of Durable Medical Equipment, Orthotics, prosthetics and other specialty equipment and related services for medical necessity. Applies established Medicare Guidelines or Benefit Interpretation criteria and standards. Responsible for collecting and interpreting medical information for appropriateness of care. Communicates determinations to all parties involved, verbally and in writing, including scope of authorization. Facilitates deployment of services and conducts retrospective review of all services when necessary. Reviews problem and complex cases with leaders. Communicates effectively with Senior Medical Leaders, physicians, individual providers and other departments for ongoing coordination of services, including hospital discharges. Negotiates rates and discounts for non-contracted vendor when necessary. Knows and interprets the MVP contracts, riders, policies and procedures. Complies cost savings reports, attends in-services and interdepartmental meetings. Develops and maintains positive relationships with physicians,
facilities and vendors. Identifies trends, new technology and policy needs. Performs other duties as assigned.

Minimum Education:

Current NYS licensure for LPN

Minimum Experience:

1-3 years clinical experience required.

Minimum of 1 - 3 years Utilization Management experience is preferred.
Utilization Management experience in a pre-paid healthcare setting is preferred.

Required Skills:
• Able to manage multiple tasks in a fast-paced environment.
• Independent thought process; oriented toward problem solving;
• Strong interpersonal and communication skills.
• Excellent computer skills

Preferred Skills:

• Previous experience with durable medical equipment and/or knowledge of HCPCS Coding is 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, 625 State Street, Schenectady, New York, United States of America