Remote Insurance Utilization Review Jobs in Rochester, NY

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.

• Growth opportunities to uplevel your career

• A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team

• Competitive compensation and comprehensive benefits focused on well-being

• An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District, one of the Best Companies to Work For in New York, and an Inclusive Workplace.

You'll contribute to our humble pursuit of excellence by bringing curiosity to spark innovation, humility to collaborate as a team, and a deep commitment to being the difference for our customers. Your role will reflect our shared goal of enhancing health care delivery and building healthier, more vibrant communities.

About the Opportunity

Qualificationsyou'llbring:

• RN with current state licensure. BS in Nursing or Health Management is preferred.
• 3+ years strong clinical background required
• Excellent verbal and written communication abilities.
• Independent thought process; oriented toward probing/problem solving

Your key responsibilities:

• Reviews inpatient medical records against established criteria and standards to determine medical appropriateness and level of care assignment.
• Review individual claims requiring clinical interpretation and judgment. Implements the operational functions of the MVP Utilization Management program as assigned.
• Potential to travel to designated locations 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 leader and the MVP Senior Medical Leaders.
• Knows and interprets the MVP contract, riders, policies and procedures.

Whereyou'llbe:

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.

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 status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam-era or special disabled Veteran or other legally protected classifications.

To support a safe, drug-free workplace, pre-employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team athr@mvphealthcare.com.