Medical Necessity
Medical Necessity is a key concept in healthcare that determines if a treatment, service, or procedure is needed for a patient's condition. It's like a justification system that healthcare providers use to show insurance companies why specific care is required. When looking at resumes or job descriptions, this term shows that the candidate understands how to properly document and determine when treatments are truly needed, which is crucial for both patient care and insurance reimbursement. Similar terms include "medical justification" or "clinical necessity." This concept is important because it helps healthcare facilities get paid by insurance companies and avoid denied claims.
Examples in Resumes
Reviewed and documented Medical Necessity for 200+ patient cases monthly
Trained staff on proper Medical Necessity documentation procedures
Achieved 95% approval rate for Medical Necessity determinations with insurance providers
Typical job title: "Medical Necessity Reviewers"
Also try searching for:
Where to Find Medical Necessity Reviewers
Professional Organizations
Online Communities
Job Resources
Example Interview Questions
Senior Level Questions
Q: How would you handle a complex case where medical necessity is unclear?
Expected Answer: A senior reviewer should discuss gathering additional documentation, consulting with clinical staff, reviewing insurance policy guidelines, and potentially arranging peer-to-peer reviews with insurance companies.
Q: How would you improve a department's medical necessity approval rates?
Expected Answer: Should discuss implementing staff training programs, creating documentation templates, establishing pre-authorization processes, and maintaining good relationships with insurance providers.
Mid Level Questions
Q: What documentation do you typically need to support medical necessity?
Expected Answer: Should mention patient history, physical examination findings, test results, treatment plans, and how these elements work together to justify the medical service.
Q: How do you handle insurance denials based on medical necessity?
Expected Answer: Should explain the appeals process, gathering additional documentation, and working with healthcare providers to strengthen the case for medical necessity.
Junior Level Questions
Q: What is medical necessity and why is it important?
Expected Answer: Should explain that it's the process of determining if healthcare services are appropriate and needed for a patient's condition, and its importance for insurance coverage and payment.
Q: How do you verify medical necessity for a routine procedure?
Expected Answer: Should discuss checking insurance requirements, reviewing patient symptoms and diagnosis, and ensuring proper documentation is in place.
Experience Level Indicators
Junior (0-2 years)
- Basic understanding of medical terminology
- Knowledge of insurance requirements
- Basic documentation review
- Understanding of common medical procedures
Mid (2-5 years)
- Complex case review
- Appeals process management
- Insurance policy interpretation
- Staff training and support
Senior (5+ years)
- Department oversight
- Policy development
- Quality improvement implementation
- Relationship management with insurers
Red Flags to Watch For
- No knowledge of basic medical terminology
- Unfamiliarity with insurance requirements and procedures
- Poor attention to detail in documentation
- Lack of understanding of healthcare compliance regulations
- No experience with medical records systems
