RN Medical Review & Utilization Specialist

Socket.dev; United States; Remote; USD 61,000 - 68,000; Full time

Job summary

Socket.dev is seeking a Medical Review Specialist, a Registered Nurse responsible for utilization review to determine medical necessity of hospital admissions and procedures. The role requires clinical expertise, documentation, and collaboration with physicians and payers to ensure compliance with MedWatch procedures, URAC standards, and state/federal guidelines.

The position emphasizes preadmission and concurrent reviews, documentation accuracy, and proactive communication with healthcare

Qualifications

• 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

• Identify caller identity by first name, title, and organization name when calls are made to or received from facilities, providers, or patients.
• Inform patient, facility, provider or other health care professionals of specific utilization management requirements upon request.
• Perform preadmission review for medical necessity of hospitalization and surgery.
• Conduct review for necessity of Second Surgical Opinions and provide instructions for obtaining SSO.
• Precertification for physical therapy based on medical necessity and assign visits.
• Review medical necessity for outpatient tests and durable medical equipment and request notes if needed.
• Perform initial and concurrent reviews during hospital stays and document outcomes.
• Refer cases to Physician Advisors when certification cannot be made.
• Forward referral forms to TPA/Payer for discharge planning and long-term cases.
• Notify insured, physician, facility, and TPA of all determinations.
• Enter and maintain program data and perform Retrospective Review as needed.
• Verify and document personnel involved in utilization review by phone.
• Manage complaints and provide copies of certification or denial determinations on the same day.
• Prioritize incoming calls by admission type and/or review type for timely processing.
• Conduct phone inquiries to hospital/physician personnel regarding patient status.
• Determine medical necessity of entire hospital stay and refer to Medical Advisors when needed.

Job description

Socket.dev is seeking a Medical Review Specialist, a Registered Nurse responsible for utilization review to determine medical necessity of hospital admissions and procedures. The role requires clinical expertise, documentation, and collaboration with physicians and payers to ensure compliance with MedWatch procedures, URAC standards, and state/federal guidelines.

The position emphasizes preadmission and concurrent reviews, documentation accuracy, and proactive communication with healthcare