Medical Necessity Specialist

4 weeks ago


Dover, Kent, United Kingdom Intermountain Healthcare Full time
Job Overview
A Medical Necessity Specialist is needed to review and analyze clinical medical necessity and level of care appeals for denials related to external audits by government and third-party payors. This role will actively manage, maintain, and communicate all levels of denial and appeal activity to appropriate stakeholders.

Salary Range
$36.35 - $54.53 per hour based on experience

About the Role
The External Audit RN is responsible for the clinical medical necessity and level of care appeals for denials related to external audits by government and third-party payors. This role will actively manage, maintain, and communicate all levels of denial and appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.

Responsibilities
This position includes but not limited to:
  1. Review and interpret governmental contractors' response letter in comparison to the medical records.
  2. Communicates with departmental stakeholders regarding missing or insufficient medical documentation.
  3. Research and apply federal regulations, law, and relevant CMS policies as a basis for appeals.
  4. Identifies and communicates root causes for denials with members of the healthcare team.
  5. Assures all discussions and appeals are filed timely with appropriate clinical rationale.
  6. Completes data entry in the audit databases for tracking, trends, and analysis.
  7. Analyzes medical records using Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines to determine the viability of the appeal and to manage the appeal process.
  8. Serves as a subject matter expert for documentation requirements, clinical disease processes and treatment, medical necessity decisions and appeal escalations.
  9. Completes ongoing education and CEU requirements to maintain licensure and certifications.

Requirements
To be successful in this role, you will need:
  1. Bachelor of Science in Nursing (BSN) preferred.
  2. Current licensure as a registered nurse in state of practice.
  3. Experience in Microsoft Office, electronic medical record systems and electronic databases.
  4. Required: Three (3) years' experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting.
  5. Preferred: Five (5) years' experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting.

Work Environment
This role will work out of our Peaks Regional Office location in Broomfield, Colorado.

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