Clinical Review & Utilization Coordinator

MedWatch; Town of Florida (NY); Hybrid; USD 32,000 - 37,000; Full time

Job summary

MedWatch seeks a Medical Review Coordinator in New York to review medical data, determine precertification decisions, and document outcomes in the clinical record. The role collaborates with the utilization review specialist and Physician Advisor to ensure timely and accurate certification following URAC and state standards.

Requirements include an LPN license in-state, an Associate degree, and 3 years of clinical nursing experience.

Qualifications

• Associate's degree or equivalent education and experience.
• Licensed Practical Nurse (current unrestricted, in state of practice).
• 3 years 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).

Responsibilities

• Review medical data obtained by mail or fax and enter into the clinical record for review by the utilization review specialist.
• Review and determine certification decision for all precertification cases forwarded to her by the utilization review specialist.
• Discuss all cases lacking clinical information to allow certification with her supervisor prior to sending to the appropriate Physician Advisor for review.
• Obtain clinical information on all pregnancy cases as directed by MedWatch protocol.
• Discuss any case with the Medical Review Specialist which may include high risk OB clinical and memo the claims office information obtained.
• At the direction of the Medical Review Specialist, discuss potential case management referrals with the case management supervisor and refer as directed to the claims office.
• Obtain discharge dates and bill totals for the Medical Review Specialist at the time of discharge to expedite closure of cases.
• Adhere to all company policies as stated in the employee handbook.
• Assist with projects as directed by the Director of Utilization Review.
• 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.

Skills

Organizational skills

Verbal communication

Written communication

Time management

Problem solving

Diplomacy

Education

Associate's degree or equivalent

Tools

MS Office

Job description

MedWatch seeks a Medical Review Coordinator in New York to review medical data, determine precertification decisions, and document outcomes in the clinical record. The role collaborates with the utilization review specialist and Physician Advisor to ensure timely and accurate certification following URAC and state standards.

Requirements include an LPN license in-state, an Associate degree, and 3 years of clinical nursing experience.