Medicare Medical Necessity Specialist

University Radiology is the largest privately-owned provider of subspecialty radiology and teleradiology services in NJ.  We are comprised of more than 200 Board Certified radiologists with advanced U.S.-based training and expertise in all modalities and subspecialty areas. In operation for more than 60 years, University Radiology staffs, manages and provides preliminary and final subspecialty interpretations and consultative support for hospitals, imaging centers and other medical facilities, and serves as the academic radiology faculty at Rutgers Robert Wood Johnson Medical School. Our physicians interpret over 2.1 million radiology procedures per year.

The Medicare Medical Necessity Specialist is responsible for validating compliance for advanced diagnostic imaging procedures prior to the service being performed.

This role focuses strictly on Traditional Medicare (Fee-For-Service) compliance, auditing incoming physician orders for clinical completeness against federal regulations. By cross-referencing clinical documentation with Centers for Medicare & Medicaid Services (CMS) policies and RAC audit denials this specialist ensures that scans meet strict medical necessity guidelines and manages the execution of Advance Beneficiary Notices (ABNs)

• Review incoming advanced diagnostic imaging orders PET/Nuclear Medicine for Traditional Medicare beneficiaries to verify that clinical documentation supports the requested procedure code (CPT/HCPCS).
• Research and apply regional Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) to ensure the patient's symptoms or diagnoses (ICD-10 codes) justify the scan.
• Notify patients in advance when orders fail to meet medical necessity guidelines resulting in an ABN being issued.

• Request/Review referring clinicians’ records to ensure the following elements are clearly documented.
  • Ordering Physician must document clearly state why the patient is strongly suspected of having cancer based on imaging, symptoms, or risk factors. 
  • Ordering Physician must document why PET is needed for treatment decisions. Example: PET ordered to determine surgical candidacy and optimal biopsy location.
  • Ordering Physician must document why prior CT results are not enough to guide the next step.  
  • Ordering Physician must document that the next treatment decision depends on what the PET shows.
  • Prior imaging/lab results have been obtained
• Identify orders that fail to meet established CMS medical necessity criteria and accurately determine when an Advance Beneficiary Notice of Noncoverage (ABN) must be issued.
  • Communicate directly to patient and/or family member regarding ABN determination and potential out-of-pocket financial responsibilities, ensuring transparency and regulatory compliance prior to exam start.

• Act as the primary point of contact between University Radiology and referring provider offices to resolve missing clinical documentation, mismatched coding, or invalid order formats.
• Educate clinical and administrative staff at referring offices on specific Traditional Medicare documentation gaps that may cause scheduling delays or billing rejections.
• Collaborate with internal radiology schedulers and technologists to ensure compliant workflow timelines are met and patient appointments are not delayed.

• Education: High school diploma or equivalent required. Associate or Bachelor’s degree in Healthcare Administration, Health Information Management (HIM), or a related clinical field is highly preferred.
• Experience: Minimum of 2–3 years of experience in front-end radiology authorization, medical intake, or utilization review within an outpatient imaging network or hospital radiology department.
• Specialized Knowledge: Deep, functional understanding of Traditional Medicare rules, including the structural navigation of LCD/NCD policy indexes, CPT/ICD-10 code pairing, and strict federal compliance regarding ABN generation and execution.
• Technical Proficiency: Hands-on experience utilizing Radiology Information Systems (RIS), Electronic Health Records (EHR), and automated medical necessity screening software.
• Certifications (Preferred): Certified Radiology Coder (RCC), Certified Professional Coder (CPC), Certified Medical Administrative Assistant (CMAA), or equivalent. A relevant clinical license (such as an LPN or ARRT Radiologic Technologist) is highly valued.
• Core Competencies: High attention to clinical detail, objective analytical judgment, strong problem-solving capabilities, and excellent verbal and written communication skills when interacting with referring medical providers and patients.

From $25/hr

University Radiology  is an Equal Opportunity Employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.