A medical review nurse evaluates patient records to determine the medical necessity of treatment. This is often used as a basis to approve and deny insurance claims. Such nurses can also work for a hospital or similar facility to help administrators make decisions about the kinds of treatment to provide and the most appropriate circumstances for potentially experimental procedures. Medical review nurses usually need to have an active nursing license and several years of experience in case management and direct patient care.
Insurance companies may have blanket policies in place to approve basic treatment without review, and send other issues to a medical review nurse. If a treatment could be questionable or a less costly alternative is available, this may trigger a review. Likewise if insurance protocols were not followed or there are concerns about the validity of a diagnosis. The medical review nurse looks at the patient record and may also meet with patients and care providers to discuss the situation. This provides an opportunity to learn about extenuating circumstances that might affect the decision.
As part of their work, medical review nurses may conduct research to learn more about unusual conditions and treatments. They typically keep up with the latest in standard protocols to understand the decisions made by care providers and may follow research in a particular area to be prepared for medical reviews. After a careful consideration of the case, the medical review nurse can issue a recommendation on how to proceed. This is accompanied with a detailed document covering the situation, actions taken, and the outcome of any research conducted to explain why the nurse approved or denied the claim.
In addition to looking at individual cases, medical review nurses can work with insurance companies on setting standards and protocols. They may argue that some diagnoses and treatments are basic and should be approved, and can provide guidelines on flagging suspect situations. This can streamline operations at the firm by allowing review personnel to focus on the cases that really need this secondary evaluation. It may also be necessary for a medical review nurse to work with insurance representatives when patients appeal denials, to go into more detail about the case and help the representative determine whether to reverse the denial of coverage.
Reviewers think about patient needs, treatment options and alternatives, and overall costs. While they are tasked with saving money for the insurance company, they are also responsible for ensuring that patients receive appropriate coverage for their treatment. If something appears to be medically indicated, even if it is expense, the medical review nurse will typically approve it.