Case Manager, Stop Loss, MVP Health Care

Posted: 05/03/18 | SHARE:


MVP Health Care is a nationally-recognized, regional not-for-profit health plan.  We are committed to having a positive impact on the health and wellness of everyone and every community we serve. We care for more than 700,000 members across New York and Vermont, and we are powered by the ideas and energy of more than 1,600 employees – providing a wide range of health benefit plan options with attentive service and flexibility normally associated with a smaller company.  Stop settling for “just a job,” and join a company where you can reach your full potential…and make a positive difference.

This position is responsible for identifying and tracking diagnosis, prognosis, and potential high costs for members triggering stop loss reporting specific to carrier and group policy requirements. This involves creating, analyzing and reviewing multiple internal and external (i.e. ASO vendor reports) reports. Communicates with stop loss carriers to correlate medical expense expectations to renewal quotes and member specific deductibles on renewals. Responds to reinsurance carriers regarding questions about plans of care and future potential costs. Interacts regularly with internal departments such as Medical Affairs and Contracting to determine possible referral facilities and research contracted or negotiated rates for high cost procedures and out of network claims. Refers identified cases that are not enrolled in MVP’s Case Management, Care Advantage or Disease Management to appropriate internal departments. Works closely with ASO Reinsurance Analysts (responsible for monthly updating and claim submission) to meet tight monthly reporting timeframes and ensure all potential claimants are included. Obtains reporting documents for Reinsurance Specialist to submit reinsurance claims. HIPAA compliant communication with marketing staff and/or group representatives may be required to tie Case Management activities to stop loss coverage or plan/policy exclusions. Performs other duties as assigned.


Minimum Education: Minimum of 2 years case management and/or stop loss experience

Minimum Experience: Registered Nurse required with BSN preferred

Required Skills:

•Some Stop Loss experience required

•Demonstrated problem-solving skills with excellent verbal and written communication abilities

•General knowledge and understanding of Claims, (DRG facilities, and claim negotiations) CM & UM Functions and MVP offered programs to assist with cost containment measures

•Strong computer skills including working knowledge of Microsoft Office including Excel/Access

•Proven success with interacting with providers on delicate matters of medical necessity and service appropriateness

•Clinical experience in an acute care clinical setting a plus.

Additional Information: 

Job ID: 1308

Status: Full Time, Exempt

MVP Health Care is an Affirmative Action/Equal Opportunity Employer). 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, 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

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