RN Utilization Review Specialist

MedWatch; Florida; Hybrid; USD 65,000 - 70,000; Full time

Job summary

MedWatch is seeking a Medical Review Specialist (RN) to conduct utilization review for hospital admissions and procedures. You will verify medical necessity, coordinate with facilities and payers, and document findings in the case record.

Ideal candidates have an Associate's degree in nursing (bachelor's preferred), an unrestricted RN license, and at least 5 years of varied clinical nursing experience. Strong organizational, communication, and problem-solving skills are essential.

Qualifications

• Associate degree in nursing; bachelor's preferred.
• Registered Nurse with current unrestricted license in state of practice.
• Minimum 5 years varied clinical nursing experience.
• Strong organization and time management abilities.
• Excellent verbal and written communication skills.
• Able to handle difficult situations tactfully and diplomatically.
• Effective problem solving and decision-making skills.
• Strong computer skills with MS Office Suite (Word, Excel, PowerPoint).

Responsibilities

• Identify patient, facility, provider, or payer information when contacted.
• Inform relevant parties of utilization management requirements as needed.
• Perform preadmission review for medical necessity of hospitalization and surgery.
• Review necessity of Second Surgical Opinions and provide instructions if needed.
• Precertify physical therapy for medical necessity and manage visit counts.
• Review medical necessity for outpatient tests and durable medical equipment and request notes if needed.
• Conduct initial and concurrent reviews during hospital stays to certify admission or treatment.
• Refer cases to Physician Advisors when criteria are not met and certification is pending.
• Coordinate with Case Management for discharge planning and communication with payers.
• Notify insured, providers, and payers of determinations; maintain case documentation.
• Enter and maintain program data; participate in Quality Management activities.
• Adhere to UR procedures and identify opportunities for improvement.
• Duties may evolve; responsibilities can change with notice.

Skills

Nursing experience

Verbal and written communication

Organizational skills

Time management

Problem solving

MS Office

Education

Associate's degree in nursing

Bachelor's degree preferred

Tools

MS Office Suite

Job description

MedWatch is seeking a Medical Review Specialist (RN) to conduct utilization review for hospital admissions and procedures. You will verify medical necessity, coordinate with facilities and payers, and document findings in the case record.

Ideal candidates have an Associate's degree in nursing (bachelor's preferred), an unrestricted RN license, and at least 5 years of varied clinical nursing experience. Strong organizational, communication, and problem-solving skills are essential.