Medical Review Specialist – RN

🔥 6 minutes ago

🇺🇸 United States – Remote

💵 $65k - $70k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

👻 Ghost score 1%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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MedWatch, LLC

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1988

💼 Consulting

📦 Logistics

🛡️ Insurance

Consulting • Logistics • Insurance

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 medical necessity of hospital admissions and outpatient procedures • Perform preadmission reviews for medical necessity of hospitalization and surgery • Assign diary dates for continued hospital stay reviews and notify facilities and doctors' offices • Review the necessity of Second Surgical Opinions and provide instructions when required • Precertify physical therapy and assign visit limits and expiration dates • Review medical necessity for designated outpatient tests and durable medical equipment • Request provider office notes and refer cases to Physician Advisors when certification cannot be completed • Perform initial, concurrent, and retrospective reviews during hospital stays and treatment • Collect information necessary to certify admissions, procedures, treatments, length of stay, and service frequency or duration • Refer non-certifiable or pending cases to Physician Advisors and Medical Directors • Send referrals for discharge planning, catastrophic illnesses, and long-term cases to Case Management • Notify claims offices, reinsurers, insureds, physicians, facilities, and TPAs of determinations • Perform data entry and reporting requirements • Verify and document utilization review personnel information • Forward utilization review complaints to the Supervisor and maintain related documentation • Provide concerned parties with certification or denial determinations the same day • Prioritize incoming calls and conduct inquiries regarding treatment, continued stay, and discharge status • Maintain knowledge of program components, medical criteria, contract requirements, state certification requirements, and URAC standards • Maintain accurate program data and perform review activities in a timely manner • Participate in the Quality Management Program and identify opportunities for service improvement • Perform other duties and responsibilities as assigned

🎯 Requirements

• Associate's degree in nursing; bachelor's preferred • Current unrestricted Registered Nurse license 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 • Proficiency in MS Office Suite products (Word, Excel, PowerPoint) • Ability to work in the United States for any employer without sponsorship • Dedicated, quiet workspace in the home

🏖️ Benefits

• Paid time off • Medical insurance • Dental insurance • Vision insurance • Short-term disability • Long-term disability • Life insurance • AD&D insurance • 401(k) with match • Critical illness coverage • Legal plan • Identity theft coverage • Pet insurance • Discount programs • Competitive compensation • Dedicated, quiet home workspace for remote work

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