BROADWAY VENTURES, LLC · 3 months ago
Medical Claims Reviewer
United States
Full-time
Remote
Mid, Senior Level
$68K/yr - $68K/yr
5+ years expBroadway Ventures is a Service-Disabled Veteran-Owned Small Business that specializes in program management and consulting solutions. They are seeking a Medical Claims Reviewer to conduct medical reviews for various claim types and ensure compliance with established criteria and guidelines. The role involves documenting decisions, supporting medical claims, and educating staff on medical reviews and coding procedures.
CommercialConsultingInsuranceProfessional Services
Responsibilities
Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations
Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
Documents medical rationale to justify payment or denial of services and/or supplies
Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
Participates in quality control activities in support of the corporate and team-based objectives
Provides guidance, direction, and input as needed to LPN team members
Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback
Assists with special projects and specialty duties/responsibilities as assigned by Management
Qualification
Required
Active, unrestricted RN licensure from the United States and in the state of hire
Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
Bachelor's degree Nursing
Graduate of accredited School of Nursing
Five years clinical experience
Two years utilization/medical review, quality assurance, or home health experience
Working knowledge of managed care and various forms of health care delivery systems
Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience
Knowledge of specific criteria/protocol sets and the use of the same
Working knowledge of word processing software
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment skills
Demonstrated customer service and organizational skills
Demonstrated oral and written communication skills
Ability to persuade, negotiate, or influence others
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion
Microsoft Office proficiency
Preferred
Five years of clinical nursing experience in Home Health, Utilization or Medical Review or Quality Assurance
Masters Degree of Nursing or similar
Computer proficient to include use of multiple screens and programs simultaneously
Benefits
401(k)
401(k) matching
Dental insurance
Disability insurance
Flexible spending account
Health insurance
Life insurance
Paid time off
Vision insurance
Work from home
Company
BROADWAY VENTURES, LLC
We deliver expert program management, cutting-edge IT, cybersecurity, and consulting solutions for government and commercial clients.
51-200 employees
Funding
Current Stage
Growth StageCompany data provided by crunchbase