Professional, Prospective Review RN

About the role

As a Prospective Review Registered Nurse, you will be responsible for evaluating medical requests, treatment plans, and high-cost services to ensure alignment with clinical guidelines and medical necessity standards. This role involves close collaboration with Medical Directors and healthcare providers to support accurate, evidence-based decision-making and promote high-quality patient outcomes across multiple lines of business. Qualifications you'll bring: Current RN (NY or VT) Minimum of 3-5 years clinical experience required Able to manage multiple tasks in a fast-paced environment. Strong clinical knowledge, critical thinking skills and understanding of medical terminology, procedures, concepts. Ability to work independently to analyze complex medical information. Effective communication skills, both written and verbal. Ability to work independently and collaboratively in a team environment. Proficiency in using computer systems and software for documentation, data entry and day-to-day work functions. Your key responsibilities: Conduct comprehensive reviews of medical records and treatment plans to determine if the requested services are appropriate based on established guidelines and medical criteria across multiple lines of business. Utilize your clinical expertise to evaluate medical necessity and collaborate with MVP Medical Directors to determine the effectiveness of proposed treatments/equipment. Document clinical summations, recommendations and send appropriate correspondences accurately and within regulatory timeframes. Communicate with healthcare providers and members to collect pertinent information, discuss review outcomes and provide appropriate referrals within MVP. Remain up to date with industry standards and guidelines, complete required competency training and proficiency examinations to ensure compliance and best practice. Participate in team meetings and training sessions to enhance your knowledge and skills. Contribute to process improvement initiatives to streamline the prospective review process. Where you'll be: Location: Remote Pay Transparency MVP Health Care is 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. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended 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. We do not request current or historical salary information from candidates. $69,383.00-$92,279.00 MVP's Inclusion Statement At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration. MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial statu

Benefits

Additional Information

Join Us in Shaping the Future of Health Care At MVP Health Care, we're on a mission to create a healthier future for everyone. That means embracing innovation, championing equity, and continuously improving how we serve our communities. Our team is powered by people who are curious, humble, and committed to making a difference-every interaction, every day. We've been putting people first for over 40 years, offering high-quality health plans across New York and Vermont and partnering with forward-thinking organizations to deliver more personalized, equitable, and accessible care. As a not-for-profit, we invest in what matters most: our customers, our communities, and our team.

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