Utilization Review RN - Medical Necessity Expert

MedWatch; États-Unis; Hybride; USD 65 000 - 70 000; Plein temps

Résumé du poste

MedWatch is seeking a Medical Review Specialist, a Registered Nurse responsible for conducting Utilization Review to validate medical necessity for hospital admissions and outpatient procedures. You will gather information from providers and facilities, document findings, and communicate decisions in compliance with URAC standards and state guidelines.

The role requires 5+ years of clinical nursing experience, an associate degree in nursing (bachelor’s preferred), and strong MS Office skills.

Qualifications

• Registered Nurse with current unrestricted license in state of practice.
• Associate degree in nursing; bachelor’s preferred.
• Minimum 5 years of varied clinical nursing experience.
• Proficient in MS Office (Word/Excel/PowerPoint).

Responsabilités

• Identify yourself by name, title, and organization when contacting facilities, providers, or patients.
• Perform preadmission review for medical necessity of hospitalization and surgery.
• Review necessity of Second Surgical Opinions; provide instructions if SSO cannot be waived.
• Precertify physical therapy for medical necessity; assign visits and expiry.
• Review medical necessity for outpatient tests and durable medical equipment; request notes as needed.
• Perform initial and concurrent reviews during hospital stays; collect necessary information.
• Refer cases to Physician Advisors when certification cannot be completed.
• Notify insured, physician, facility, and TPA of determinations.
• Enter and maintain program data; participate in quality management.

Connaissances

Organizational skills

Time management

Verbal communication

Written communication

Decision making

MS Office proficiency

Formation

Associate degree in Nursing

Bachelor’s degree preferred

Outils

MS Office Suite

Word

Excel

PowerPoint

Description du poste

MedWatch is seeking a Medical Review Specialist, a Registered Nurse responsible for conducting Utilization Review to validate medical necessity for hospital admissions and outpatient procedures. You will gather information from providers and facilities, document findings, and communicate decisions in compliance with URAC standards and state guidelines.

The role requires 5+ years of clinical nursing experience, an associate degree in nursing (bachelor’s preferred), and strong MS Office skills.