Medical Review Specialist/RN

MedWatch•, (Multiple States)

4d•$64,000 - $68,000•Hybrid

About The Position

The Medical Review Specialist is a Registered Nurse who conducts the Utilization Review process by obtaining medical information and confirming the medical necessity of hospital admissions and/or outpatient procedures. The Medical Review Specialist will perform her/his duties in accordance with MedWatch procedures outlined below, MedWatch review standards, URAC standards and state certification requirements and federal guidelines.

Requirements

Registered Nurse (current unrestricted, in state of practice)
Minimum 5 years varied clinical nursing experience.
Good organizational skills and time management
Excellent verbal and written communication skills
Ability to handle difficult situations tactfully and diplomatically.
Effective problem solving and decision-making skills.
Strong computer skills with proficiency in MS Office Suite products (Word, Excel, PowerPoint)

Nice To Haves

Associate's degree in nursing, bachelor's preferred.

Responsibilities

Identify her/himself by first name, title, and organization name when a call is made to or received from a facility, provider or patient.
Upon request, inform the patient, facility, provider or other health care professionals of specific utilization management requirements or procedures.
Perform preadmission review for medical necessity of hospitalization and surgery.
Assign diary date for review of continued hospital stay; inform hospital utilization review department and doctor’s office of date next review needed.
Perform review for necessity of Second Surgical Opinions. If SSO cannot be waived, provide instructions for obtaining SSO.
Precert physical therapy for medical necessity. Assign number of visits and expiration date.
Perform review of medical necessity for designated outpatient tests and durable medical equipment.
Perform initial and concurrent reviews during hospital stays.
Refer cases to Physician Advisors when procedures or hospital stays cannot be certified and certification must be pended.
Send referral forms to TPA/Payer for discharge planning, catastrophic illnesses and long-term cases to Case Management.
Notify claims office and re-insurer.
Notify insured, physician, facility, and TPA of all determinations.
Perform data entry and reporting requirements.
Perform Retrospective Review when requested or when medical information cannot be obtained prior to or during confinement or treatment.
Verify and document the name and department of the personnel performing utilization review by telephone.
Forward all verbal or written complaints concerning utilization review to the Supervisor for disposition.
Provide all concerned parties with a copy of the certification or denial determination.
Prioritize incoming calls by admission type and/or review type in order to facilitate timely processing.
Conduct phone inquiries to hospital/physician personnel regarding patient continued stay treatment and discharge status.
Determine medical necessity, of entire hospital stay or treatment days, and make referrals to Medical Advisors.
Maintain accurate, current knowledge about program components: Preadmission certification, Pretreatment certification, Second Opinion, Continued stay and treatment review, Alternative care assessment, Discharge Planning, Retrospective Review.
Maintain current knowledge regarding the medical criteria and its application with specific focus on all preadmission and treatment criteria.
Maintain accurate knowledge with regards to company specific contract requirements and/or considerations, state certification requirements and URAC standards.
Maintain effective, diplomatic working relationship with insured, patients and providers and payers.
Enter and maintain accurate program data.
Perform review activities according to Utilization Review Procedures in a timely manner.
Refer cases to physician advisors when medical criteria are not met, during certification or on an appeal.
Participate in the Quality Management Program by adhering to all company policies and procedures and identifying opportunities for improvement to ensure quality services are rendered to clients and customers.