Patient Access Medical Necessity Analyst II – Pre - Services

Patient Access Medical Necessity Analyst II – Pre - Services

Job Category: Clerical

Schedule: Full time

Shift: 1 - Day Shift

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.

• 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.
• 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.
• Perform related duties as assigned.

EDUCATION: 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.