Job Details

SUMMARY:

The Medical Necessity Analyst II is responsible for advanced pre-service reviews of clinical documentation, ensuring compliance with payer-specific medical necessity criteria. This role serves as a subject matter expert, providing guidance to Analyst I staff and collaborating with clinical teams to resolve complex documentation issues. The Analyst II supports quality improvement initiatives and contributes to the development of best practices in documentation review.

ESSENTIAL FUNCTIONS:
• Conduct detailed reviews of the content of clinical documentation for scheduled procedures to ensure compliance with current published specific payer medical necessity guidelines.
• Serve as a resource and mentor for Analyst I staff, providing training and support.
• Collaborate with providers and office staff, clinical departments, and revenue cycle teams to resolve complex clinical documentation gaps.
• Utilize EHR systems and payer portals to verify CPT codes and payer requirements.
• Coordinate with Authorization and Patient Access teams to ensure consistency in service planning.
• Escalate high-risk or ambiguous cases to leadership or Utilization Management RNs.
• Contribute to process improvement initiatives.
• Maintain accurate documentation of findings, communications, and outcomes in EHR and tracking systems.
• Maintain confidentiality and adhere to HIPAA and organizational policies.
• Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION: High school diploma or GED and knowledge of medical terminology required. Associate degree in healthcare administration, health information management, medical coding, or related field preferred

EXPERIENCE: Three (3) years in a hospital or medical office setting with experience in clinical documentation review.

LICENSURE OR CERTIFICATION: None required. CPC, RHIT, CHDS, CHDP, or equivalent certification preferred.

KNOWLEDGE, SKILLS, AND ABILITIES:
• Advanced critical thinking and analytical skills.
• Strong written and verbal communication.
• Proficiency in EHR systems, Microsoft Office, payer portals, and other software.
• Ability to manage multiple tasks and lead documentation initiatives.
• In-depth knowledge of commercial and government insurance guidelines.
• Expertise in medical terminology, clinical documentation standards, and CPT codes.
• Healthcare documentation specialist preferred.