Medicare Medical Necessity Specialist

University Radiology • East Brunswick Township, NJ

5d • Onsite

About The Position

University Radiology is seeking a part-time Medicare Medical Necessity Specialist for its East Brunswick, New Jersey Business Office. The position works 25 hours per week and validates Traditional Medicare (Fee-For-Service) compliance for advanced diagnostic imaging procedures before services are performed. The specialist audits incoming physician orders for clinical completeness against federal requirements, applies CMS policies and RAC audit denials, determines whether scans meet medical necessity guidelines, and manages Advance Beneficiary Notices (ABNs).

Requirements

• High school diploma or equivalent.
• At least 2–3 years of experience in front-end radiology authorization, medical intake, or utilization review within an outpatient imaging network or hospital radiology department.
• Functional understanding of Traditional Medicare rules, including LCD/NCD policy indexes, CPT/ICD-10 code pairing, and federal requirements for ABN generation and execution.
• Hands-on experience with Radiology Information Systems (RIS), Electronic Health Records (EHR), and automated medical necessity screening software.
• High attention to clinical detail, objective analytical judgment, problem-solving ability, and strong verbal and written communication skills for interactions with providers and patients.

Nice To Haves

• Associate or bachelor’s degree in Healthcare Administration, Health Information Management (HIM), or a related clinical field.
• Certification such as Certified Radiology Coder (RCC), Certified Professional Coder (CPC), Certified Medical Administrative Assistant (CMAA), or equivalent.
• A relevant clinical license, such as LPN or ARRT Radiologic Technologist.

Responsibilities

• Review incoming advanced diagnostic imaging orders for PET and Nuclear Medicine procedures for Traditional Medicare beneficiaries, verifying that clinical documentation supports the requested CPT/HCPCS procedure code.
• Research and apply regional Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) to verify that symptoms or diagnoses support the requested scan.
• Notify patients in advance when orders do not meet medical necessity guidelines and an ABN is required.
• Request and review referring clinicians’ records to confirm required documentation, including the suspected cancer rationale, the need for PET to guide treatment decisions, why prior CT results are insufficient, whether the next treatment decision depends on PET results, and whether prior imaging and laboratory results have been obtained.
• Identify orders that fail CMS medical necessity criteria and determine when an Advance Beneficiary Notice of Noncoverage (ABN) must be issued.
• Communicate ABN determinations and potential out-of-pocket costs to patients and/or family members before the exam begins.
• Serve as the primary contact between University Radiology and referring provider offices to resolve missing clinical documentation, mismatched coding, and invalid order formats.
• Educate clinical and administrative staff at referring offices about Traditional Medicare documentation gaps that may cause scheduling delays or billing rejections.
• Work with internal radiology schedulers and technologists to meet compliant workflow timelines and prevent patient appointment delays.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: High school or GED