About this role
Role Overview
- Conduct comprehensive utilization reviews to determine medical necessity and level of care
- Review medical records for documentation completeness and clinical appropriateness
- Evaluate inpatient, outpatient, and procedural services for compliance with payer guidelines
- Assist with preparation and review of demand packages for legal and insurance cases
- Analyze cases involving payer disputes, denials, and recoupments
- Prepare detailed, defensible written clinical review reports
- Provide affidavit support, deposition preparation, and testimony when required
- Interpret CMS guidelines, Medicare policies, and state-specific Medicaid requirements
- Identify clinical risk, quality-of-care concerns, and documentation deficiencies
Requirements
- Active, unrestricted Registered Nurse (RN) license
- Minimum 5–7 years of clinical experience
- At least 3–5 years of utilization review, medical necessity review, or case review experience
- Demonstrated experience performing reviews in multiple states
- Strong knowledge of Medicare, Medicare Advantage, Medicaid, and commercial payer criteria
- Experience applying InterQual or MCG guidelines preferred
- Prior litigation support, deposition, or expert testimony experience strongly preferred
- Excellent written analytical and report-writing skills
- Ability to work independently and meet strict deadlines
- Experience with inpatient and outpatient level-of-care determinations
- Appeals and denial review experience
- Experience supporting personal injury or civil litigation cases
- Background in case management or compliance review