Sub-Acute RN UM Reviewer - Medicare

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. What’s in it for you: 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 As a Sub-Acute RN UM Reviewer-Medicare, you will play a vital role in our Utilization Management team by conducting clinical reviews to ensure appropriate use of healthcare services. This position is essential for maintaining compliance with Medicare guidelines and supporting high-quality patient outcomes. The ideal candidate will bring strong clinical judgment, experience in sub-acute care settings, and a commitment to improving healthcare delivery through effective collaboration and discharge planning. Qualifications you’ll bring: Current and unrestricted NY & VT RN licensure Associate or bachelor’s degree in nursing (BSN preferred) Minimum 3 years of clinical nursing experience At least 2 years of experience in utilization management of sub-acute Medicare reviews Strong knowledge of sub-acute care, rehabilitation, and skilled nursing services Proficiency in interpreting medical records and applying medical necessity criteria Understanding of discharge planning process and transitional care need Excellent communication, critical thinking, and organizational skills. Your key responsibilities: Conduct timely and accurate utilization reviews for sub-acute Medicare cases. Evaluate medical necessity, level of care, and appropriateness of services based on established criteria and guidelines. Support and assess discharge planning efforts to ensure continuity of care and appropriate post-acute services. Collaborate with providers, facilities, and interdisciplinary teams to ensure optimal patient care and resource utilization. Document review outcomes and maintain compliance with regulatory and organizational standards. Participate in audits, quality improvement initiatives, and training sessions. Maintain current knowledge of Medicare regulations and UM best practices. 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 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 at [email protected]. At MVP Health Care, we’re more than a health insurance company—we’re a mission-driven organization committed to creating a healthier future for all. We believe in the power of innovation, collaboration, and continuous improvement to drive meaningful change.