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. 

• Perform review of medical necessity for designated outpatient tests and durable medical equipment. MedWatch does not routinely require hospitals, physicians, and providers to numerically code diagnoses or procedures to be considered for certification, but may request such codes if available. If the Medical Review Specialist is unable to certify the requested outpatient procedure with the information provided telephonically, she will request the provider office notes pertaining to this procedure and fax them to the Physician Advisor for review and determination.  MedWatch shares all clinical and demographic information on individual patients among our clerical and case management departments that have a need to know, to avoid duplicate request for information from enrollees or providers. 

• Perform initial and concurrent reviews during hospital stays. MedWatch collects only the information necessary to certify the admission, procedure or treatment, length of stay, or frequency or duration of services. MedWatch does not routinely request copies of all medical records on all patients reviewed. Only the sections of the medical record necessary in that specific case to certify medical necessity or appropriateness of the admission or extension of stay, frequency or duration of service, or length of anticipated inability to return to work are requested. 

• Refer cases to Physician Advisors when procedures or hospital stays cannot be certified and certification must be pended. 

• Send referral forms to TPA/Payer for discharge planning, catastrophic illnesses and long-term cases to Case Management. Notify claims office and re-insurer. 

• Notify insured, physician, facility, and TPA of all determinations. 

• Perform data entry and reporting requirements. 

• Perform Retrospective Review when requested or when medical information cannot be obtained prior to or during confinement or treatment.  MedWatch issues a determination within 15 days of a request for a utilization management determination.  For retrospective review, the organization bases review determinations solely on the medical information available at the time the medical care was provided. 

• Verify and document the name and department of the personnel performing utilization review by telephone.  

• Forward all verbal or written complaints concerning utilization review to the Supervisor for disposition. Disposition may be a written or a verbal contact to attempt to resolve the complaint issue. Documentation of written/verbal contacts should be maintained in the case record and employee file if appropriate. 

• Provide all concerned parties with a copy of the certification or denial determination.  The copy shall be sent the same day as determination. 

• Prioritize incoming calls by admission type and/or review type in order to facilitate timely processing. 

• Conduct phone inquiries to hospital/physician personnel regarding patient continued stay treatment and discharge status. 

• Determine medical necessity, of entire hospital stay or treatment days, and make referrals to Medical Advisors. 

• Maintain accurate, current knowledge about program components: 

• Preadmission certification 

• Pretreatment certification 

• Second Opinion 

• Continued stay and treatment review 

• Alternative care assessment 

• Discharge Planning 

• Retrospective Review 

• Maintain current knowledge regarding the medical criteria and its application with specific focus on all preadmission and treatment criteria. 

• Maintain accurate knowledge with regards to company specific contract requirements and/or considerations, state certification requirements and URAC standards. 

• Maintain effective, diplomatic working relationship with insured, patients and providers and payers.   

• Enter and maintain accurate program data. 

• Perform review activities according to Utilization Review Procedures in a timely manner. 

• Refer cases to physician advisors when medical criteria are not met, during certification or on an appeal (refer to Appeal Policy). Follow physician referral procedure of: 

• initial referral to Medical Director and, if unresolved, 

• referral to a specialist who is a peer to the attending physician. 

• Participate in the Quality Management Program by adhering to all company policies and procedures and identifying opportunities for improvement to ensure quality services are rendered to clients and customers. 

• The incumbent may be responsible for duties or responsibilities that are not listed in this job description. Duties and responsibilities may change at any time with or without notice. 

The pay range for this position is $64,000.00 - $68,000.00 annually.

Work Environment / Physical Demands:  This position is in a typical office / home office environment which requires prolonged sitting in front of a computer.  Requires hand-eye coordination and manual dexterity sufficient to operate standard office equipment including operation of standard computer and phone equipment.   

We are an Equal Opportunity Employer including disability/veterans.