[Hiring] Medical Review Specialist @MedWatch

Role Description

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, MedWatch review standards, URAC standards, state certification requirements, and federal guidelines.

Qualifications

• Associate's degree in nursing, bachelor's preferred.
• Registered Nurse (current unrestricted, in state of practice).
• Minimum 5 years varied clinical nursing experience.

Requirements

• 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).

Duties and Responsibilities

• Identify herself/himself by first name, title, and organization name when a call is made to or received from a facility, provider, or patient.
• 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.
• 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.
• Send referral forms to TPA/Payer for discharge planning, catastrophic illnesses, and long-term cases to Case Management.
• 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.
• Maintain current knowledge regarding the medical criteria and its application.
• Maintain effective, diplomatic working relationship with insured, patients, providers, and payers.
• Enter and maintain accurate program data.
• Perform review activities according to Utilization Review Procedures in a timely manner.
• Participate in the Quality Management Program by adhering to all company policies and procedures.
• The incumbent may be responsible for duties or responsibilities that are not listed in this job description.

Benefits

• The salary range for this position is from $61,000 to $68,000 annually.

Work Environment / Physical Demands

This position is in a typical office/home office environment which requires prolonged sitting in front of a computer. Requires hand-eye coordination and manual dexterity sufficient to operate standard office equipment including operation of standard computer and phone equipment.

E.O.E.