Medical Review Nurse

Jobtailor; New York (NY); On-site; USD 70,000 - 95,000; Full time

Job summary

Jobtailor is seeking a qualified DME pre-authorization reviewer in the United States (New York). The role focuses on assessing medical necessity for DMEPOS across multiple categories and ensuring alignment with coverage policies.

You will collaborate with healthcare providers and internal teams, bridging documentation gaps, educating stakeholders on evolving criteria, and upholding HIPAA and PHI privacy standards in every workflow.

Qualifications

• 3–5+ years in DME pre-authorizations or related reviews.
• Proficient with medical review software and EHR platforms.
• Excellent written and verbal communication.
• Ability to thrive in fast-paced environment with flexible mindset.
• Strong collaborative team player.
• Adheres to PHI guidelines and privacy protocols.
• Familiarity with InterQual and/or MCG criteria preferred.
• Experience reviewing Surgical Dressings, CGMs, Insulin Pumps, Wound Care, Ostomy, Urology, and CPAP/PAP therapy preferred.

Responsibilities

• 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 PHI across all workflows

Skills

DME Pre-Authorizations

Utilization Management Reviews

Medical Review Software Proficiency

InterQual Review Criteria

PHI Compliance

HIPAA Compliance

Tools

EHR Platforms

Medical Review Software

Job description

• 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 InterQual 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
• InterQual 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