Medical Review Nurse
Listed on 2026-09-14
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Healthcare
Medical Records
• Review DMEPOS orders, progress notes, and medical records against coverage policies to confirm medical necessity across diverse DME categories
• Communicate findings clearly with healthcare providers and internal teams
• Bridge documentation gaps and educate stakeholders on evolving coverage criteria
• Maintain strict compliance with HIPAA
• Enforce disciplined handling of Protected Health Information (PHI) across all workflows
Requirements
- Prior experience (3 - 5+ years) with DME pre-authorizations, DME utilization management reviews and/or DME claim audit processes
- Standard computer literacy and proficiency with medical review software/EHR platforms
- Excellent written and verbal communication skills with the ability to convey complex policy requirements clearly
- Proven ability to thrive in a fast-paced environment with a flexible, adaptable mindset
- Strong team player with a highly collaborative work style
- Strict adherence to PHI guidelines and patient privacy protocols
- Familiarity with Inter Qual and/or MCG review criteria preferred
- Experience reviewing Surgical Dressings, CGMs, Insulin Pumps, Wound Care, Ostomy, Urology, and CPAP/PAP therapy preferred
Core Competencies
Demonstrates expertise in DME pre-authorizations, utilization management, and compliance with HIPAA regulations while effectively communicating complex policy requirements to healthcare providers and internal teams.
Highest-signal resume keywords
- DME Pre-Authorizations
- Utilization Management Reviews
- Medical Review Software Proficiency
- Inter Qual Review Criteria
- PHI Compliance
ATS Optimization Keywords
Hard Skills
- DME Claim Audit Processes
- Medical Necessity Review
- Documentation Gap Bridging
- Coverage Policy Analysis
- Surgical Dressing Review
- CGM Review
- Insulin Pump Review
- Wound Care Review
- Ostomy Review
- Urology Review
Soft Skills
- Excellent Written Communication
- Excellent Verbal Communication
- Collaborative Work Style
- Adaptability
- Team Player
Industry Keywords
- DMEPOS
- HIPAA Compliance
- Protected Health Information
- Patient Privacy Protocols
Tools & Technologies
- EHR Platforms
- Medical Review Software
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