Medical Necessity Review Nurse - Remote

Overview

The Medical Necessity Review Nurse examines medical records and performs front end medical necessity reviews of ordered services through pre-authorization services, serving as a subject matter expert in the revenue cycle department.

In Short

• Evaluate requested services for medical necessity.
• Review documentation in medical records.
• Communicate medical necessity to payers.
• Research and prepare appeal files for clinical denials.
• Track and trend denial issues for process improvement.
• Participate in process improvement initiatives.
• Manage a diverse workload in a fast-paced environment.
• Maintain professional relationships for positive outcomes.
• Utilize extensive knowledge of medical terminology and coding systems.
• Work independently without close supervision.

Requirements

• Associate or Bachelor’s degree in Nursing.
• Three years of experience in patient care or revenue cycle management.
• Registered Nurse or Licensed Practical Nurse preferred.
• Prior medical necessity review experience preferred.
• Knowledge of managed care industry and payer structures.
• Critical thinking and assessment skills.
• Ability to develop professional relationships.
• Self-motivated and independent worker.

Benefits

• Standard office environment.
• Reasonable accommodations for individuals with disabilities.
• Opportunities for professional development.
• Collaboration with multidisciplinary staff.
• Participation in process improvement initiatives.