MVP Health Care

Collaborate with various business units to resolve accumulator issues, analyze errors for process improvement, and respond to member inquiries while documenting resolutions and participating in status meetings to enhance healthcare delivery.

Title: Associate, Claims Examiner Location: Virtual US NY Remote Full time job requisition id JR100219 Job Description: 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. Qualifications you'll bring: - High School Diploma required. Associate degree in health, Business or related field preferred - The availability to work Full-Time, Virtual in Schenectady or Rochester - Previous related health care experience required - Knowledge of CPT, HCPCS, ICD-9-CM coding systems and Medical terminology preferred. - Strong PC skills required, Microsoft Windows experience highly desired. Strong attention to detail. - 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: - Using a PC /Microsoft Window environment, adjudicates claims with the aid of the Facets and Macess Systems. - Reviews and ensures the accuracy of all provider, member and claim line information for all claims for which the examiner is responsible. - Knowledge of Facets and Macess systems strongly preferred, but not required. - Reviews and ensures the accuracy of all changes to claim line information based on information received from other departments and in accord with available benefit information. - Is responsible for the timely and accurate adjudication of claims that are suspended to other MVP departments for benefit and/or authorization determination. - Meets or exceeds department quality and work management standards for claims adjudication. - Successfully completes a course of comprehensive formal training in all areas of benefits determination, system navigation, and MVP policy. - Suspends, investigates and resolves claim issues by coordinating with appropriate departments, based on criteria set by those departments. - Handles inquiries regarding suspended claims from other departments and identifies trends in suspensions based on these inquiries and other feedback. - Keeps abreast of all benefit changes. - 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 within Rochester, NY or Schenectady, NY 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. $20.00-$26.60 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.

Role Description Join Us in Shaping the Future of Health Care at MVP Health Care, where we’re on a mission to create a healthier future for everyone. Our team is powered by people who are curious, humble, and committed to making a difference—every interaction, every day. - 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. Qualifications - Curiosity to spark innovation - Humility to collaborate as a team - Commitment to enhancing health care delivery - Ability to build healthier, more vibrant communities Requirements - 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 Benefits - Base pay range: $51,395.00-$68,354.75 - Comprehensive benefits focused on well-being Company Description MVP Health Care is committed to creating healthier communities by nurturing a healthy workplace. We strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. - MVP is an equal opportunity employer - We recruit, employ, train, compensate, and promote without discrimination based on various 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 hr@mvphealthcare.com .

Role Description The Clinical Coordinator (CC) will work directly with customers, their families and/or advocates to ensure that the member has access to MVP resources offered through the Long-Term Support and Services (LTSS) Program. The CC works collaboratively with the RN case manager to support, promote, and facilitate engagement in the LTSS Case Management Program. - Act as a bridge between the customer, the health plan, and Community-based Organizations to create a seamless and positive experience. - Build individual capacity by increasing health and wellness self-management skills through outreach, education, encouragement, social supports, and advocacy. - Evaluate the needs of the customer between assessment timeframes and inform the RN case manager of any changes in member status. - Empower the customer to make informed decisions and advocate on their behalf when necessary. - Collaborate with a broader team, including Case Management, Social Work, and the Medical Director. - Develop care plan interventions that maintain cost-effective care and reduce/resolve challenges or barriers. - Communicate regularly with the member to promote engagement and utilization of Plan benefits. Qualifications - Bachelor’s Degree in a Health or Human Service field preferred, or a combination of an Associate’s Degree in a health or human services field and 2 years of experience working within managed care or health services environment, or 5 years of experience as a service coordinator with any population. - Working knowledge of Medicaid programs. - Extensive knowledge and experience with Medicaid LTSS benefits, community organizations, social services, and public resources. - Experience in Managed Care and/or working with Medicaid or Social Service Agencies a plus. - Ability to incorporate Evidence Based Innovation (EBI) practices into customer engagement. - Ability to collaboratively work with a team to assist and resolve member concerns and complaints. - Ability to adhere to New York State Medicaid regulatory guidelines. - Understanding of the time tasking tool, person-centered plan of care, and the NFloc scoring methodology. - Highly organized; capacity to work independently and manage multiple priorities appropriately. - Ability to communicate independently and directly with members, providers, and staff with calmness, assertiveness, diplomacy, and in a non-confrontational manner. Requirements - Build lasting relationships with members, families, and caregivers. - Conduct new Member Medicaid Long Term Support Services (LTSS) follow-up calls and complete ongoing SDOH assessments. - Ensure complete communication feedback to/from customers regarding service delivery and ongoing health status. - Promote customer understanding of their diagnosis and treatment plan. - Assist customers in addressing unmet needs and recommend community-based supports as necessary. - Facilitate reduction of care disruption or delays in care. - Facilitate access to culturally appropriate services that meet the customers’ stated needs. - Promote knowledge of health delivery systems to empower members into self-care management. - Support patient-centric strategies to improve health and wellness in collaboration with the RN Case Manager. - Collaborate with MVP Quality Management to support performance measurements. - Facilitate resolution of real and perceived disruptions of care as the customer enrolls in MVP LTSS program. Benefits - Growth opportunities to uplevel your career. - A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences. - Competitive compensation and comprehensive benefits focused on well-being. - An opportunity to shape the future of health care by joining a recognized team. Company Description MVP Health Care is committed to creating healthier communities by nurturing a healthy workplace. We strive to create space for individuals from diverse backgrounds to have a voice and thrive.

Role Description Join Us in Shaping the Future of Health Care at MVP Health Care, where we’re on a mission to create a healthier future for everyone. Our team is powered by people who are curious, humble, and committed to making a difference—every interaction, every day. You’ll contribute to our humble pursuit of excellence by bringing: - Curiosity to spark innovation - Humility to collaborate as a team - 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. Qualifications - Associate degree preferred (or equivalent relevant work experience) - The availability to work full-time, remote within NYS - Medical claims processing analysis skills with strong attention to detail and quality control focus - 3+ years of experience in a related field (accumulator data exchanges and/or health insurance claims processing) preferred - 3+ years of experience using Microsoft Word and Excel preferred - Critical thinking and problem-solving/troubleshooting skills - 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 Requirements - Partner with Sales/Marketing, Pharmacy, Claims Operations, and other business units to communicate and resolve accumulator issues aligned with organizational strategy and values - Investigate and resolve accumulator-related issues tied to medical, pharmacy, and behavioral health claims using Facets and Macess systems while meeting assigned project goals - Review, analyze, and evaluate accumulator errors using existing and new data reports; identify root causes and trends, document resolutions, and opportunities for process improvement - Respond to member service calls and inquiries regarding accumulator inquiries, coordinate resolution with impacted internal departments and MVP partners - Document information in the appropriate location; participate in meetings on accumulator objectives, issues, and progress; help maintain current training and process documentation - Run and interpret reports to identify impacted claims, dollar volume, and group/member impact; proactively identify process and efficiency opportunities for accumulator data transmissions - Participate in upper management meetings as needed to provide status updates, communicate risks and impacts, and present findings and recommendations clearly and professionally to internal stakeholders and vendors, as needed - 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 Benefits - 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 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. We do not request current or historical salary information from candidates. Salary range: $24.00-$31.92 MVP's Inclusion Statement At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. 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 various 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 hr@mvphealthcare.com .

• Using a PC /Microsoft Window environment, adjudicates claims with the aid of the Facets and Macess Systems. • Reviews and ensures the accuracy of all provider, member and claim line information for all claims for which the examiner is responsible. • Reviews and ensures the accuracy of all changes to claim line information based on information received from other departments and in accord with available benefit information. • Is responsible for the timely and accurate adjudication of claims that are suspended to other MVP departments for benefit and/or authorization determination. • Meets or exceeds department quality and work management standards for claims adjudication. • Successfully completes a course of comprehensive formal training in all areas of benefits determination, system navigation, and MVP policy. • Suspends, investigates and resolves claim issues by coordinating with appropriate departments, based on criteria set by those departments. • Handles inquiries regarding suspended claims from other departments and identifies trends in suspensions based on these inquiries and other feedback. • Keeps abreast of all benefit changes. • 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.

• Execute outbound campaigns with a primary focus on driving member retention, while supporting quality objectives, welcoming new members to plan offerings, and achieving defined campaign-specific goals • Must have the ability to work in a fast-paced environment and manage the challenges inherent with a call center atmosphere while delivering excellent service on every call • Meet individual accessibility and outreach goals and team goals for industry standard benchmarks • Demonstrate excellent communication skills, applying soft skills during interactions with diverse clientele • Develops a comprehensive understanding of all lines of business • On an ongoing basis, educates members about their benefits and MVP’s procedures • Manages first call resolutions and perform tasks efficiently; adhering to guidelines on call avoidance, average handle time, hold time, and after call work • Research information needed to correctly respond to customer concerns • Asks appropriate questions to ensure a clear understanding of customer’s concern • Delivers service with integrity • Clearly explains all policies and procedures on both incoming and out-going calls. • Applies technical skills required to simultaneously access multiple databases while addressing customer needs • Documents all customer contacts, performing data input in a highly accurate manner • Serve as a liaison between our internal and external customers, always representing the company in a professional and courteous manner • Conducts outbound campaigns for all lines of business, must be self-directed, organized, confident, and able to flex communication and presentation skills to the needs of the customer • Responsible for researching and resolving member issues and for communicating resolution back to the caller in a timely, professional and effective fashion • Successfully uses contacts to facilitate issue resolution and interacts appropriately with all involved • Obtains NYS Market Place Facilitated Enroller certification also known as Certified Application Counselor (CAC) within 1st year from date of hire.

Role Description 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 - 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 Requirements - 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 Benefits - 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

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 The Quality Data Analyst will be accountable for performing analyses to support operational workflows within MVP’s Health Care Quality Analytics team. The ideal candidate will also participate in automation efforts that create efficiencies and help to create a data-driven organization. The Quality Data Analyst will work with cross-functional teams, including business, technical, and Data Governance teams, to ensure the availability, accuracy, and reliability of health care quality related data. This position will also be responsible for building robust reporting to enhance MVP’s health care quality programs and drive better outcomes. The ideal candidate will have some experience working with NCQA and CMS quality measures and HEDIS data to support improved health care outcomes and member satisfaction. ​ Qualifications you'll bring: - Bachelor’s Degree in Health Administration, Statistics, Economics, Health Informatics, Computer Science, Epidemiology or related field. - 1 years’ experience in a business environment involving the analysis of financial or other large data sets. Masters’ Degree in relevant field may be considered in lieu of this experience. - Demonstrated problem-solving and analytical abilities. - Proficiency in SQL, data visualization tools (e.g. Tableau, PowerBI), and data manipulation tools (e.g. Alteryx, R, Python). - Demonstrated ability to work independently with strong attention to detail. - Ability to manage multiple projects and produce results within deliverable timelines. - Demonstrated excellent written and verbal communication skills. - Ability to transform analytical output into simple to understand findings. - Intermediate Word skills, including the ability to create moderately complex documents containing tables and graphs. - Intermediate Microsoft Excel skills, including the ability to create simple formulas, insert rows, link data, enter and sort data and produce graphs and charts. - Proven ability to analyze, report and provide insight on large sets of data. - Data visualization skills (Tableau, Power BI, etc.). - Preferred Job Skills - Previous Health Insurance experience preferred - R or Python - Subject matter expertise of healthcare industry quality metrics and HEDIS standards - Clinical data analytics - Project management Your key responsibilities: - Participate in the execution of operational workflows and quality data deliverables. - Conduct analysis of large data sets to support quality improvement initiatives, including gap analysis, process optimization, and patient engagement. - Build reporting dashboards for the clinical quality team to track measures and initiatives. - Ensure the accuracy and integrity of data through data quality control processes and procedures. - Participate in the development of data governance policies, standards, and procedures, and ensure compliance with regulatory requirements and industry best practices. - Continuously monitor and evaluate the effectiveness of operational workflows, making recommendations for improvements and leading implementation efforts as necessary. - Other duties as assigned by leadership. Where you'll be: Virtual 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 hr@mvphealthcare.com.

• Client Relationship Management • Sales Growth & Revenue Generation • Customer Onboarding & Support • Negotiation & Contract Management • Collaboration with Internal Teams • Market Intelligence Reporting & Analysis • Problem-Solving • Compliance & Documentation • Other duties as assigned by leadership.