UM Prospective Review, Professional, Prospective Review - LPN
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.
Current NYS licensure for LPN
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.
• 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
• 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 firstname.lastname@example.org.
- Job Family Medical Management/Clinical
- Pay Type Salary
- Headquarters Office, 625 State Street, Schenectady, New York, United States of America