Scope:
The Medical Review Coordinator will perform her/his duties in accordance with MedWatch procedures, MedWatch review standards, URAC standards and state certification requirements.
License Requirements:
Licensed Practical Nurse (current unrestricted, in state of practice)
Education:
2-year degree, L.P.N.
Experience:
3 years clinical nursing experience.
Responsibilities:
- Review medical data obtained by mail or fax and enter into the clinical record for review by the utilization review specialist.
- Review and determine certification decision for all precertification cases forwarded to her by the utilization review specialist. Document all information obtained according to MedWatch policy. Follow up post procedure to obtain the pathology report as appropriate and send a notification memo to the claims office advising of the results and any additional treatment needed.
- Discuss all cases lacking clinical information to allow certification with her supervisor prior to sending to the appropriate Physician Advisor for review. Follow up to assure PA response timely within MedWatch guidelines.
- Obtain clinical information on all pregnancy cases as directed by MedWatch protocol.
- Discuss any case with the Medical Review Specialist which may include high risk OB clinical and memo the claims office information obtained. Forward the case to the assigned utilization review specialist for followup at the time of delivery.
- At the direction of the Medical Review Specialist, discuss potential case management referrals with the case management supervisor and refer as directed to the claims office.
- Obtain discharge dates and bill totals for the Medical Review Specialist at the time of discharge to expedite closure of cases.
- Adhere to all company policies as stated in the employee handbook.
- Assist with projects as directed by the Director of Utilization Management.
- 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.
We are an Equal Opportunity Employer including Veterans and Disability
About Medwatch LLC
Are you ready to take your career to the next level? At MedWatch, we are a community of passionate, driven individuals who thrive on innovation and collaboration. For over 35 years, MedWatch has partnered with clients to develop innovative and effective solutions to address their needs. By mitigating risk within the plan population and focusing on quality care and improved outcomes, MedWatch reduces healthcare expenditures for the plan and plan member. We offer competitive compensation and a comprehensive benefits package including Paid Time Off, Medical, Dental, Vision, Short and Long-Term Disability, Life Insurance, AD&D, 401k with match, critical illness coverage, and discount programs.