Medical Necessity Review Specialist

3 weeks ago


Uniondale, New York, United States HumanEdge Allied Health Full time
About the Role

Are you a dedicated and detail-oriented nurse looking for a challenging role that utilizes your clinical expertise? We are seeking an experienced Utilization Review Nurse to join our team in a hybrid position, combining both in-office and remote work.

This exciting opportunity is based in Uniondale, Long Island, Nassau County, where you will play a vital role in ensuring the appropriate use of medical resources while delivering high-quality care management.

Key Responsibilities
  • Conduct thorough reviews to ensure proper utilization of medical services.
  • Evaluate patient records to assess service necessity and appropriateness.
  • Collaborate with healthcare providers to optimize outcomes.
  • Analyze clinical data to assess medical necessity.
  • Recommend actions using evidence-based guidelines.
  • Communicate with insurers to secure coverage and authorizations.
  • Maintain detailed documentation to meet compliance standards.
  • Participate in case management and care coordination meetings.
Requirements

To be successful in this role, you should have:

  • An active RN license in New York State.
  • At least 2 years of experience in utilization review.
  • Strong knowledge of medical terminology and healthcare services.
  • Excellent communication and interpersonal skills.
  • A self-starter with effective time management skills.
  • Proficiency with EHR systems and utilization management tools.


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