Medical Review Coordinator / LPN

MedWatch; Lorida (FL); Hybrid; USD 32,000 - 37,000; Full time

Job summary

MedWatch is seeking a Medical Review Coordinator to handle clinical data review, precertification decisions, and documentation in accordance with URAC standards and state requirements.

Ideal candidates have an associate degree plus 3 years nursing experience, LPN licensure, and strong MS Office skills. The role involves collaboration with medical staff and claims to ensure timely, accurate certification and patient care decisions.

Qualifications

• Associate’s degree or equivalent education and experience.
• Current unrestricted LPN license in state of practice.
• At least 3 years of clinical nursing experience.
• Strong organizational and time management skills.
• Excellent verbal and written communication skills.
• Ability to handle difficult situations tactfully and diplomatically.
• Proficient in MS Office Suite (Word, Excel, PowerPoint).

Responsibilities

• Review medical data received by mail or fax and enter into the clinical record for review by the utilization review specialist.
• Review and determine certification decisions for precertification cases; document information per MedWatch policy and notify claims office of results and follow-up needs.
• Coordinate with supervisor and Physician Advisor to obtain timely PA response within MedWatch guidelines.
• Obtain clinical information on pregnancy cases as directed by protocol.
• Discuss cases with Medical Review Specialist and forward for follow-up at delivery.
• Refer potential case management as directed to the case management supervisor.
• Obtain discharge dates and bill totals to expedite case closure and maintain records.
• Adhere to all company policies and participate in Quality Management program.
• Other duties as assigned by the Director of Utilization Review.

Skills

Organizational skills

Verbal and written communication

Tactful communication

Problem solving

Education

Associate’s degree or equivalent education

Tools

MS Office Suite (Word, Excel, PowerPoint)

Job description

Scope:

The Medical Review Coordinator will perform her/his duties in accordance with MedWatch procedures, MedWatch review standards, URAC standards and state certification requirements.

Education:

• Associate’s degree or equivalent education and experience

Licensure/Certification Requirements:

• Licensed Practical Nurse (current unrestricted, in state of practice)

Experience:

• 3 years clinical nursing experience.

Requirements/Skills:

• 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:

• 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. Document all information obtained according to MedWatch policy. Follow-up post procedure to obtain the pathology report as appropriate and send a notification memo to the claims office advising of the results and any additional treatment needed.
• Discuss all cases lacking clinical information to allow certification with her supervisor prior to sending to the appropriate Physician Advisor for review. Follow up to assure PA response timely within MedWatch guidelines.
• 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. Forward the case to the assigned utilization review specialist for follow-up at the time of delivery.
• 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.
• The incumbent may be responsible for duties or responsibilities that are not listed in this job description. Duties and responsibilities may change at any time with or without notice.

The salary range for this position is from $23 to $27 per hour.

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.