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Medical Claims Reviewer

United States - Remote

At Broadway Ventures, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth. Built on integrity, collaboration, and excellence, we’re more than a service provider—we’re your trusted partner in innovation.

Medical Review Nurse (Full-Time, Remote)

Join our Medical Review team! We are seeking a dedicated RN to conduct medical reviews for pre- and post-payment claims. This role involves utilizing clinical/medical information provided by physicians and providers, following established criteria/protocol sets or clinical guidelines, and documenting decisions accordingly. You’ll also provide support in reviewing medical claims and utilization practices.

Position Details

  • Job Type: Full-time (40 hours/week)
  • Schedule: Monday-Friday, 8:00 AM – 4:30 PM
  • Location: Remote U.S. (Work from home)
  • Requirements for Remote Work: High-speed internet (non-satellite) and a private, lockable home office
  • Salary: $67,700 annually, paid bi-monthly (twice a month)

Key Responsibilities

  • Conduct medical claim reviews for medically complex services, pre-authorization requests, appeals, fraud/abuse referrals, and correct coding claims.
  • Make payment determinations based on clinical/medical information and established guidelines.
  • Assess the medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
  • Document the medical rationale to support the approval or denial of services/supplies.
  • Educate internal and external staff on medical reviews, coverage determinations, and coding procedures.
  • Participate in quality control activities to support corporate and team objectives.
  • Provide guidance to LPN team members as needed.
  • Offer educational support to non-medical staff through discussions, meetings, and classroom participation.
  • Assist with special projects or responsibilities as assigned by management.

Minimum Qualifications

  • Licensure:
    • Active, unrestricted RN licensure in the United States and in the state of hire
      OR
    • Active compact multistate unrestricted RN license (as defined by the Nurse Licensure Compact).
  • Education:
    • Associate Degree in Nursing
      OR
    • Graduate of an accredited School of Nursing.
  • Required Experience:
    • Two years of clinical experience plus two years of utilization/medical review, quality assurance, OR home health experience.
  • Skills:
    • Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings.
    • Knowledge of specific criteria/protocol sets and the ability to use them effectively.
    • Proficiency with word processing software and Microsoft Office.
    • Ability to work independently, prioritize tasks, and make sound decisions.
    • Excellent customer service, communication, organizational, and critical thinking skills.
    • Ability to handle confidential information with discretion.

Preferred Qualifications

  • Three years of clinical nursing experience in Home Health, Utilization Review, Medical Review, or Quality Assurance (strongly preferred).
  • Proficient with computers, including the ability to use multiple screens and programs simultaneously.

What to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with the most qualifies candidates.

We perform a background and drug test prior to the start of every new hires' employment. Broadway Ventures is an equal opportunity employer and VEVRAA Federal Contractor. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

 

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