Utilization Review Nurse – Medical Necessity Expert

MedWatch; Oregon; 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 outpatient procedures. You will verify medical necessity, coordinate with providers, and ensure compliance with URAC standards and state guidelines.

The role requires an RN with at least five years of clinical nursing experience, strong organization, and excellent communication skills. The position offers a hybrid work arrangement and opportunities to contribute to quality management.

Qualifications

• Must be a Registered Nurse (current, unrestricted, in-state)
• Minimum 5 years varied clinical nursing experience
• Strong organizational skills and time management
• Excellent verbal and written communication skills
• Proficient in MS Office (Word, Excel, PowerPoint)

Responsibilities

• Identify yourself by name, title, and organization when contacting facilities, providers, or patients.
• Conduct preadmission reviews for medical necessity of hospitalization and surgery.
• Review for necessity of Second Surgical Opinions and provide instructions if SSO is required.
• Precertify physical therapy for medical necessity and set visit counts/expiration.
• Review medical necessity for outpatient tests and durable medical equipment; request notes as needed for physician review.
• Perform initial and concurrent reviews during hospital stays to certify admission, procedure, or treatment.
• Refer cases to Physician Advisors when criteria are not met and certification is pending.
• Notify insured, physician, facility, and payer of determinations and maintain documentation.
• Enter and maintain program data and perform retrospective reviews as requested.
• Maintain knowledge of medical criteria, URAC standards, and state requirements.

Skills

Org & time mgmt

Verbal & written comms

Tactful & diplomatic

Problem solving

MS Office Suite

Education

Associate's degree in nursing

Bachelor's degree preferred

Job description

MedWatch is seeking a Medical Review Specialist (RN) to conduct utilization review for hospital admissions and outpatient procedures. You will verify medical necessity, coordinate with providers, and ensure compliance with URAC standards and state guidelines.

The role requires an RN with at least five years of clinical nursing experience, strong organization, and excellent communication skills. The position offers a hybrid work arrangement and opportunities to contribute to quality management.