Medical Review Specialist, RN

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MedWatch, LLC

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1988

⚕️ Healthcare Insurance

🤝 B2B

Healthcare Insurance • B2B

MedWatch, LLC is a healthcare services company that provides utilization management, case management, disease management, member advocacy and concierge care coordination to payers, TPAs, and self‑insured employers. For over 35 years it has delivered clinically driven care management, precertification and claims solutions, direct contracting and ancillary services backed by URAC accreditations and proprietary in‑house technology to improve clinical outcomes and reduce plan and member costs.

📋 Description

• Conduct the Utilization Review process by obtaining medical information and confirming the medical necessity of hospital admissions and/or outpatient procedures • Identify her/himself by first name, title, and organization name when a call is made to or received from a facility, provider, or patient • Perform preadmission review for medical necessity of hospitalization and surgery • Assign diary date for review of continued hospital stay • Perform review for necessity of Second Surgical Opinions • Precert physical therapy for medical necessity • Perform review of medical necessity for designated outpatient tests and durable medical equipment • Perform initial and concurrent reviews during hospital stays • Notify claims office and re-insurer • Conduct phone inquiries to hospital/physician personnel regarding patient continued stay treatment and discharge status

🎯 Requirements

• Associate's degree in nursing, bachelor's preferred • Registered Nurse (current unrestricted, in state of practice) • Minimum 5 years varied clinical nursing experience • 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)

🏖️ Benefits

• Paid time off • Medical insurance • Dental insurance • Vision insurance • Short and long-term disability • Life insurance • AD&D • 401k with match • Critical illness coverage • Legal plan • Identity theft coverage • Pet insurance • Discount programs