Medical Review Coordinator / LPN

Scope: The Medical Review Coordinator will perform her/his duties in accordance with MedWatch procedures, MedWatch review standards, URAC standards and state certification requirements.

Education:

• Associate’s degree or equivalent education and experience

Licensure/Certification Requirements:

• Licensed Practical Nurse (current unrestricted, in state of practice)

Experience:

• 3 years 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:

• 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 follow-up 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 Review.

• 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 salary range for this position is from $23 to $27 per hour.

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.

E.O.E.

Originally posted on Himalayas