Leader, Physical Health Prospective And Retrospective UM

Over 35 years strong and fueled by 1,700 smart, passionate employees across New York state and Vermont, MVP is full of opportunities to grow. We are a nationally recognized, award-winning leader for a reason. The beating heart of our company is a wide range of employees from a diverse set of backgrounds-tech people, numbers people, even people people-working together to make health insurance better. If you are ready to join a thriving, mission-driven company where you can create your own opportunities and make a positive difference-it's time to make a healthy career move to MVP!

Status: Full Time, Exempt

Provides professional oversight, leadership and guidance over the day-to-day operation of the Utilization Management (UM) Prospective and Retrospective leaders and teams. Assures compliance w/ Federal, State, NCQA, other regulatory agencies, & internal standards & requirements. Keeps current on all state and federal regulations affecting UM activities. Monitors UM literature at the state and national level to ensure that MVP remains at the forefront of effective member focused UM. Ensures the development, implementation, coordination, and evaluation of the team's job responsibilities. Performs quality checks and supports the team in meeting their productivity measures. Designs and maintains processes and workflows to support internal programs and coordination with other interfaces as relevant. Interviews, recommends for hire, orients, evaluates, and counsels team members. Resolves complex issues with leadership and staff. Receives and analyzes performance and activity reports, creating action plans as required. Knows and interprets MVP contracts, policies, and procedures. Acts as a liaison between the utilization management teams and internal staff, Medical Directors, community partners and other MVP service providers. Interacts with other departments to define data requests, test system performance, and evaluate process improvement opportunities. Interacts with Member Services, Provider Relations, Quality Improvement, and Finance to identify utilization trends. Works with the Vice President of Health and Pharmacy Management, Vice President of Medical Affairs, and Director of Behavioral Health to ensure all UM functions are coordinated and enhance the member experience. Performs other duties as assigned.

POSITION QUALIFICATIONS

Minimum Education:

RN with active license required,

BSN or BA/ BS degree in healthcare related field such as management, health services administration preferred.

Relevant master's degree in a related field such as nursing, business, or health services administration ideal.

Minimum Experience:

Five (5) or more years of experience in utilization management within a health plan required. Hospital or other UM experience may be considered.

Progressive leadership is experience required. Significant management experience in a managed care or HMO setting strongly preferred.

Leadership skills including people management experience and demonstrated effectiveness in influencing and managing professional staff.

Experience in medical cost management strategic plan development and execution

Experience with utilization and cost analytics and proven record of application of trend mitigation.

Required Skills:

• Demonstrated knowledge of operations and healthcare management; NCQA, CMS, and other local, state, and federal regulations

• Knowledge of managed care operations, process improvement and techniques

• Ability to interpret and analyze data necessary to identify trends, evaluate trend impacts operationally, fiscally and from a quality perspective and development and managed corrective action activities.

• Familiarity with Medicare and State Medicaid programs and hands-on experience with regulatory requirements and reporting.

• Familiarity with utilization management process: prospective and retrospective review.

• Demonstrated experience in managing clinical nursing staff including recruitment, education, and training.

• Excellent communication and relationship development skills with health professionals and business colleagues.

• Strong leadership, relationship building, and mentoring skills.

• Ability to work independently and prioritize multiple assignments to meet deadlines.

• Highly effective interpersonal and conflict management skills.

• Ability to use discretion in handling confidential information.

• Excellent oral and written communication skills.

• Organizational and Time Management skills.

• Excellent Customer Service.

• Strong analytical and critical thinking skills.

• Knowledge of process development, systems management, policy development and work-flow design.

• Knowledge of chronic health conditions, evidence-based practice guidelines and clinical tools used to demonstrate compliance with practice recommendations.

• Proven success interacting with sensitive health issues, medical necessity, and service appropriateness.

• Proficient in the use/application of standard computer applications (word, access, excel, power point).

• Valid NYS Driver's license with capacity to travel and reliable transportation.

About MVP

MVP Health Care is a nationally recognized, not-for-profit health insurer caring for members in New York and Vermont. Committed to the complete well-being of our members and the communities we serve, MVP makes health insurance more convenient, more supportive, and more personal. We are powered by the ideas and energy of more than 1,700 diverse employees from all backgrounds, committed to having a positive impact on the health and wellness of everyone we serve.

At MVP, we are 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. Specific employment offers and associated compensation will be made 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.

In addition, we offer a comprehensive benefits package that includes:

• Considerable paid time away from work including PTO (Paid Time Off), sick time, service time off, paid holidays, and floating holidays, allowing you to take time off when it suits you best.

• Competitive 401(k) employer matching and profit-sharing program to help you save for your retirement.

• Low premium health benefits including medical, dental, and vision coverage to support your well-being and that of your family.

• Life insurance and disability coverage to ensure financial security for you and your dependents.

• An array of optional benefit plans such as accident insurance and specified disease coverage to protect you from the unexpected.

• Full tuition reimbursement (up to the IRS limit) for approved courses and programs that support continuous learning.

• A best-in-class employee Well-Being program to support all dimensions of your health and wellness.

MVP Health Care analyzes the latest market data to determine employee compensation. Compensation figures listed in a job posting are subject to change as new market data becomes available. The salary range, other compensation, and benefits information is accurate as of the date of this posting. MVP Health Care reserves the right to modify this information at any time, subject to applicable law. More detailed information about totalcompensation and benefits will be provided during the hiring process.

MVP Health Care is an Affirmative Action/ Equal Employment Opportunity (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), and the Know your Rights 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 hr@mvphealthcare.com

Please apply and learn more - including how you may become a proud member of our team.

Other details

• Job Family Medical Management/Clinical

• Pay Type Salary

• Min Hiring Rate $75,780.00

• Max Hiring Rate $148,930.00

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• 220 Alexander St, Rochester, NY 14607, USA
• 303 S Broadway # 230, Tarrytown, NY 10591, USA
• 625 State St, Schenectady, NY 12305, USA
• Vermont, USA