Medical Review Coordinator / LPN

About the role

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

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.

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.

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)

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.

Pay

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