RN Medical Review Specialist - Utilization & Certification

MedWatch; Lorida (FL); On-site; USD 65,000 - 70,000; Full time

Job summary

MedWatch is seeking a Medical Review Specialist (Registered Nurse) to conduct Utilization Review for hospital admissions and outpatient procedures. You will verify medical necessity, gather clinical data, and coordinate with facilities, providers, and payers.

Strong MS Office skills and excellent communication are essential. The role requires an RN with at least 5 years of varied clinical nursing experience, and a preference for a Bachelor’s degree.

Qualifications

• Associate's degree in nursing required; bachelor's preferred.
• Registered Nurse (current unrestricted in state of practice).
• Minimum 5 years varied clinical nursing experience.
• Strong organizational, time management, and communication skills.
• Proficient in MS Office Suite (Word, Excel, PowerPoint).

Responsibilities

• Identify yourself by name, title, and organization when contacting facilities, providers, or patients.
• Perform preadmission review for medical necessity of hospitalization and procedures.
• Review for second surgical opinions and provide steps if SSOs are not waived.
• Conduct initial and concurrent reviews during hospital stays for medical necessity.
• Refer cases to Physician Advisors when certification cannot be completed.
• Notify insured, providers, and payers of determinations in a timely manner.
• Maintain documentation and program data per Utilization Review procedures.

Skills

Organizational skills

Verbal communication

Written communication

Difficult situations handling

Decision making

Time management

Education

Associate's degree in nursing

Bachelor's degree preferred

Tools

MS Office

Word

Excel

PowerPoint

Job description

MedWatch is seeking a Medical Review Specialist (Registered Nurse) to conduct Utilization Review for hospital admissions and outpatient procedures. You will verify medical necessity, gather clinical data, and coordinate with facilities, providers, and payers.

Strong MS Office skills and excellent communication are essential. The role requires an RN with at least 5 years of varied clinical nursing experience, and a preference for a Bachelor’s degree.