Department: Health Services

Position Summary:
Tracks and influences the services provided to MVP members as they move from home to hospital, extended care facility or community resource. 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. Implements the operational functions of the MVP Utilization Management program as assigned. Travels to designated location to access medical information. 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. Reviews complex cases with individual providers or supervisors and Medical Directors. Knows and interprets the MVP contract, riders, policies and procedures Perform other duties as assigned.

Requirements:

• RN with 3+ years strong clinical background required. BS in health management or administration is preferred. Minimum of 1 year UM experience is preferred.
• Demonstrated problem-solving skills with excellent verbal and written communication abilities; Familiarity with Diagnoses and Procedural Coding Practices.
• Independent thought process; oriented toward probing/problem solving. Strong PC skills. May need to travel to designated locations.

Status: Full Time

Type: Exempt

In order to be considered for this position, please apply online. Questions? Please Contact: