Medical Necessity Specialist

1 week ago


Rosedale, Maryland, United States Medstar Full time

**About the Role**

We are seeking a highly skilled Medical Necessity Specialist to join our team at Medstar. As a key member of our denial management process, you will play a crucial role in reducing financial risk and exposure by appealing denied claims.

**Responsibilities:**

  • Coordinate and monitor the denial management and appeals process
  • Collaborate with physicians, Utilization Review RNs, Case Managers, revenue cycle personnel, and payers to appeal denials
  • Evaluate external denials for medical necessity and coordinate decision-making regarding appeal feasibility
  • Develop medical summaries of denied cases for review by hospital administration and possible legal action
  • Identify and implement strategies to avoid denials and improve care efficiency through denial review and examination
  • Maintain records of concurrent and retrospective denial activity in conjunction with Case Management support staff
  • Monitor and track denials and appeal results, coordinating information with Patient Financial Services (PFS)

**Requirements:**

  • Associate's degree in Nursing required; Bachelor's degree preferred
  • 3-4 years clinical experience required; 2-3 years UR experience in a healthcare setting preferred
  • 1-2 years background/experience in hospital audits preferred
  • RN license in the District of Columbia or State of Maryland depending on work location upon hire
  • Certification in Utilization Review, Case Management, and Healthcare Quality upon hire preferred

**Salary Range:** $87,318 - $157,289 per year



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