A medical review nurse examines patient records to determine whether treatment is medically necessary. This is frequently used as a criterion for approving or denying insurance claims. Nurses in this profession can also work for a hospital or other similar facility, assisting administrators in making decisions about the types of treatment to provide and the best conditions for potentially experimental procedures. Medical review nurses typically require a current nursing license as well as several years of case management and direct patient care experience.
Insurance companies may have policies in place that allow them to approve basic treatments without review while referring other issues to a medical review nurse. A review may be initiated if a treatment appears to be questionable or if a less expensive alternative is available. Similarly, if insurance policies were not followed or if a diagnosis’ validity was questioned. The medical review nurse examines the patient’s medical record and may meet with patients and caregivers to discuss the situation. This gives you the chance to learn about any extenuating circumstances that might influence your decision.
Medical review nurses may conduct research as part of their job to learn more about unusual conditions and treatments. They usually stay up to date on standard protocols in order to understand the decisions made by care providers, and they may also follow research in a specific area in order to be prepared for medical reviews. The medical review nurse can make a recommendation on how to proceed after careful consideration of the case. This is accompanied by a detailed document that explains why the nurse approved or denied the claim, including the situation, actions taken, and the results of any research conducted.
Medical review nurses can work with insurance companies to set standards and protocols in addition to looking at individual cases. They may argue that some diagnoses and treatments are basic and should be approved, and they can also provide guidelines for identifying potentially dangerous situations. This can help the firm run more efficiently by allowing reviewers to focus on the cases that really need to be looked at again. When patients appeal denials, a medical review nurse may be required to work with insurance representatives to go over the case in greater detail and assist the representative in deciding whether to reverse the denial of coverage.
Patients’ needs, treatment options and alternatives, and overall costs are all considered by reviewers. They are responsible for ensuring that patients receive appropriate coverage for their treatment while also saving money for the insurance company. The medical review nurse will usually approve something if it appears to be medically necessary, even if it is costly.