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Medical Necessity Specialist


Medical Records


Medical Records


Full Time


Minimum Entry Level Qualifications:

  1. Experience and/or level of competency:
  • Experience Required: 3 + years of healthcare-related experience.
  • High School graduate or equivalent required.
  • College degree preferred.
  • Prior CDM or charge capture experience required.
  1. Academic Preparation:
  • High School or GED
  • Preferred - applicable clinical or professional certifications and licenses such as LVN, Certified Outpatient Coder (COC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS) highly desirable.

Job Summary:

Under the general supervision of the Revenue Cycle Leadership, a Medical Necessity Specialist is responsible for maintaining a positive, helpful attitude and approach in providing excellent customer service to all customers which include; patients, clients, referral sources, physicians, and sales representatives in verifying benefits and coverage with the health plan, sending out and obtaining medical necessity documentations in a timely manner.

Specific Responsibilities:

  • Responsible for creating, sending out and/or obtaining all medical necessity documentations in a timely manner and log information in the system.
  • Maintains and updates all medical necessity information in the system such as patient information, payer changes, and other information to support billing process.
  • Communicates with physicians offices, medical groups, MSO, and health plans on a daily basis for medical necessity documentation and for the continuation of patient equipment.
  • Communicates to Lead or Supervisor or Manager regarding progress, updates, problems, error trends, new findings, inaccurate or untimely claim submission, and others in a timely manner.
  • Maintains a daily follow-up system and checks the starting & expiring dates of medical necessity documentations.
  • Submits appropriate documentation such as prescription, labs results, medical justification, authorization, eligibility, and others as necessary and applicable in a timely manner.
  • Works on Hold Revenue report, group projects, goals and renewal process.
  • Maintains accurate and complete daily productivity report.
  • Performs other duties as assigned.
  • Remains knowledgeable on product and insurance coverage issues in order to inform
  • patients of copays and other benefit information
  • Attends all departmental meetings, company meetings, and in-services
  • Reports to work daily and is ready to work at the scheduled start time
  • Performs any other duties that may be requested by supervisor or management
  • To remain knowledgeable to date on all products, guidelines and insurance coverage trends
  • Maintain a professional safe and clean work environment.
  • Understand and adheres to all of VVRMC company policies.
  • Perform all other duties as assigned and required
  • Must meet minimum of monthly goals

Knowledge, Skills and Abilities:

  • Analytical/Critical thinking
  • Problem solving
  • Knowledge and application of ICD-10-CM, HCPCS, and CPT-4 classification systems
  • Excellent written and verbal communication skills
  • Competent with computers, Microsoft Office, Electronic Medical Records, and various electronic coding resources

Professional Requirements:

  • Adheres to dress code; appearance is clean and neat.
  • Completes annual educational requirements.
  • Maintains regulatory requirements including all state, federal and CIHQ regulations related to the HIM Department and, as appropriate, to the facility.
  • Reports to work on time and as scheduled; completes work within designated time.
  • Wears identification on duty; uses computerized punch time system correctly.
  • Attends annual review and performs departmental in-services.
  • Holds staff meetings, provides minutes of the meeting to HIM Department staff members.
  • Attends committee and management meetings as appropriate.
  • Ensures patient confidentiality and privacy at all times.
  • Resolves personnel concerns at the department level, utilizing the grievance process as required.
  • Ensures compliance with policies and procedures regarding department operations, fire, and safety and infection control.
  • Effectively and consistently communicates administrative directives to personnel and encourages interactive departmental meetings and discussions.
  • Represents the organization in a positive and professional manner.
  • Complies with all organizational policies regarding ethical business practices.
  • Communicates the mission, ethics and goals of the facility, as well as the focus statement of the department.
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