Job Description
Scope: The Medical Review Specialist is a Registered Nurse who conducts the Utilization Review process by obtaining medical information and confirming the medical necessity of hospital admissions and/or outpatient procedures. The Medical Review Specialist will perform her/his duties in accordance with MedWatch procedures outlined below, MedWatch review standards, URAC standards and state certification requirements and federal guidelines. Education: Associate's degree in nursing, bachelor's preferred. Licensure/Certification Requirements: Registered Nurse (current unrestricted, in state of practice) Experience: Minimum 5 years varied clinical nursing experience. Requirements/Skills: Good organizational skills and time management Excellent verbal and written communication skills Ability to handle difficult situations tactfully and diplomatically. Effective problem solving and decision-making skills. Strong computer skills with proficiency in MS Office Suite products (Word, Excel, PowerPoint) Duties and Responsibilities: The Medical Review Specialist will identify her/himself by first name, title, and organization name when a call is made to or received from a facility, provider or patient. Upon request, the patient, facility, provider or other health care professionals are informed of specific utilization management requirements or procedures. Perform preadmission review for medical necessity of hospitalization and surgery. MedWatch accepts clinical information from the provider, the utilization review department of the facility and/or any reasonable source that will assist in the utilization review process. Assign diary date for review of continued hospital stay; inform hospital utilization review department and doctor’s office of date next review needed. Perform review for necessity of Second Surgical Opinions. If SSO cannot be waived, provide instructions for obtaining SSO. Precert physical therapy for medical necessity. Assign number of visits and expiration date.
