Medical Review Specialist/RN
WFA Digital Insight
The demand for skilled medical review specialists has grown significantly, with a 25% increase in job postings over the past year. As the healthcare industry continues to evolve, companies like MedWatch are looking for experienced registered nurses to navigate complex utilization reviews. With a strong foundation in clinical nursing and excellent communication skills, candidates can thrive in this role. The ability to work independently and make informed decisions is crucial, and proficiency in MS Office Suite products, particularly Excel, is a must. Before applying, candidates should be aware of the need for strong problem-solving skills and the ability to handle sensitive situations tactfully.
Job Description
About the Role
The Medical Review Specialist/RN plays a critical role in conducting utilization reviews for MedWatch, ensuring that hospital admissions and outpatient procedures meet medical necessity standards. This position requires a deep understanding of clinical nursing practices, excellent communication skills, and the ability to work independently. As a key member of the MedWatch team, the Medical Review Specialist/RN will collaborate with healthcare professionals, patients, and facilities to gather necessary information and make informed decisions.The day-to-day responsibilities of this role involve conducting preadmission reviews, assigning diary dates for continued hospital stays, and performing reviews for medical necessity of various procedures and equipment. The Medical Review Specialist/RN will also interact with patients, providers, and facilities to inform them of utilization management requirements and procedures.
MedWatch operates in a fast-paced environment, and the Medical Review Specialist/RN must be able to prioritize tasks, manage time effectively, and maintain accurate records. The company values strong organizational skills, attention to detail, and the ability to handle difficult situations tactfully.
What You Will Do
- Conduct preadmission reviews to determine medical necessity of hospitalization and surgery
- Assign diary dates for review of continued hospital stays and inform hospital utilization review departments and doctor's offices of the next review date
- Perform reviews for medical necessity of second surgical opinions, precertification of physical therapy, and designated outpatient tests and durable medical equipment
- Gather clinical information from providers, facilities, and other sources to inform utilization reviews
- Communicate with patients, facilities, and healthcare professionals to inform them of utilization management requirements and procedures
- Collaborate with Physician Advisors to determine medical necessity and appropriateness of admissions and procedures
- Perform data entry and reporting requirements to maintain accurate records
- Conduct retrospective reviews when requested or when medical information cannot be obtained prior to or during confinement or treatment
- Refer cases to Physician Advisors when procedures or hospital stays cannot be certified
- Notify claims offices, reinsurers, insured individuals, physicians, facilities, and TPAs of determinations and outcomes
What We Are Looking For
- Registered Nurse (RN) licensure in the state of practice
- Associate's degree in nursing (Bachelor's degree preferred)
- Minimum 5 years of varied clinical nursing experience
- Excellent verbal and written communication skills
- Strong problem-solving and decision-making skills
- Ability to handle difficult situations tactfully and diplomatically
- Proficiency in MS Office Suite products, particularly Excel
- Good organizational skills and time management
- Ability to work independently and as part of a team
Nice to Have
- Experience with utilization review processes and managed care
- Knowledge of URAC standards and state certification requirements
- Familiarity with electronic health records and data management systems
- Certification in a specialized area of nursing practice
Benefits and Perks
- Competitive salary (dependent on experience)
- Comprehensive health insurance package
- Paid time off and holidays
- Remote work stipend and equipment support
- Professional development opportunities and continuing education support
- Collaborative and dynamic work environment
- Recognition and reward programs for outstanding performance
- Flexible scheduling to support work-life balance
How to Stand Out
- When applying, highlight your experience with utilization reviews and managed care, as well as your proficiency in MS Office Suite products, particularly Excel.
- Showcase your ability to work independently and make informed decisions, as well as your strong problem-solving and communication skills.
- Be prepared to discuss your understanding of clinical nursing practices and your experience with electronic health records and data management systems.
- Emphasize your ability to handle difficult situations tactfully and diplomatically, and your strong organizational skills and time management.
- Research MedWatch's company culture and values to demonstrate your enthusiasm for the role and the organization.
- Prepare examples of your experience with retrospective reviews, precertification of physical therapy, and designated outpatient tests and durable medical equipment.
- Be ready to discuss your approach to continuing education and professional development, and how you stay current with industry changes and best practices.
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