Leader clinical

At MVP Health Care, we’re on a mission to create a healthier future for everyone – which requires innovative thinking and continuous improvement. To achieve this, we’re looking for a Leader, Clinical Appeals, to join #TeamMVP. If you have a passion for patient advocacy, clinical integrity, and collaboration across teams this is the opportunity for you.

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.

Qualifications you’ll bring:

• Registered Nurse (RN) required, BSN preferred
• Active, unrestricted RN license
• Minimum 5 years of clinical nursing experience
• At least 3-5 years in appeals, utilization management, case management in a managed care setting
• 5+ years of supervisory experience preferred
• Strong attention to detail and ability to manage multiple tasks simultaneously.
• Excellent communication skills, both written and verbal.
• Exceptional customer service skills and ability to handle difficult situations with empathy and professionalism.
• Proficient in using computer systems and software, including Microsoft Office Suite.
• Ability to lead a team in a fast-paced environment.
• Strong organizational and time management skills.
• Familiarity with InterQual/MCG, Medicare Advantage guidelines, Medicaid state-specific rules and Commercial appeals standards
• Strong understanding of medical necessity criteria and clinical documentation standards
• Curiosity to foster innovation and pave the way for growth
• Humility to play as a team
• Commitment to being the difference for our customers in every interaction

Your key responsibilities:

• Supervise and mentor the Clinical Appeals RN team, providing clinical oversight and guidance.
• Ensure timely, complete and regulatory-compliant processing of clinical appeals and complaints.
• Review escalated or complex appeal cases for medical necessity, appropriateness of care and benefit coverage.
• Monitor team productivity and quality, providing coaching and performance management as needed
• Collaborate with the Medical Directors and other clinical leaders for physician-reviewed cases.
• Maintain up to date knowledge of CMS, NCQA and state regulations governing appeals and complaints.
• Develop process workflows, job aids and training materials for clinical team
• Analyze appeals trends and root causes to recommend opportunities for clinical improvement
• Other duties as assigned by leadership.
• Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer.

Where you’ll be:

Virtual in NYS

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 at [email protected].