RN Utilization Review Specialist

MedWatch; Tallahassee (FL); Hybrid; USD 65,000 - 70,000; Full time

Job summary

MedWatch is seeking a Medical Review Specialist (Registered Nurse) to conduct Utilization Review, verify medical necessity for hospital admissions and outpatient procedures, and ensure compliance with URAC and state/federal guidelines. Requires strong nursing background, 5+ years clinical experience, and proficient MS Office skills.

This role may involve coordination with facilities, providers, and payers. The incumbent will perform preadmission and concurrent reviews, communicate

Qualifications

• Associate degree in nursing; bachelor's degree preferred.
• Registered Nurse with current unrestricted license in state of practice.
• Minimum 5 years varied clinical nursing experience.

Responsibilities

• Identify self by first name, title, and organization when contacting facility, provider or patient.
• Perform preadmission review for medical necessity of hospitalization/surgery.
• Review necessity of Second Surgical Opinions and provide instructions if needed.
• Perform medical necessity reviews for outpatient tests and durable medical equipment.
• Refer cases to Physician Advisors when criteria are not met or for appeals.

Skills

Organizational skills

Verbal communication

Written communication

Diplomatic tact

Problem solving

Time management

Education

Associate degree in nursing

Bachelor's degree preferred

Tools

MS Office Suite (Word, Excel, PowerPoint)

Job description

MedWatch is seeking a Medical Review Specialist (Registered Nurse) to conduct Utilization Review, verify medical necessity for hospital admissions and outpatient procedures, and ensure compliance with URAC and state/federal guidelines. Requires strong nursing background, 5+ years clinical experience, and proficient MS Office skills.

This role may involve coordination with facilities, providers, and payers. The incumbent will perform preadmission and concurrent reviews, communicate