BROADWAY VENTURES, LLC · 3 days ago
Remote RN – Medical Claims Reviewer
United States
Full-time
Remote
Mid Level
4+ years expBroadway Ventures is a Service-Disabled Veteran-Owned Small Business that specializes in expert program management and innovative consulting solutions. They are seeking a dedicated Registered Nurse to join their Medical Review team, responsible for conducting medical reviews to ensure compliance with clinical criteria and guidelines.
CommercialConsultingInsuranceProfessional Services
Responsibilities
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
Assess payment determinations using clinical information and established guidelines
Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement
Provide clear, well-documented rationales for service approvals or denials
Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
Support quality control activities to meet corporate and team objectives
Provide guidance to LPN team members and support non-clinical staff through training and discussions
Assist with special projects and additional responsibilities as assigned
Qualification
Required
Active, unrestricted RN license in the U.S. and in the state of hire
Active compact multistate RN license (as defined by the Nurse Licensure Compact)
Associate Degree in Nursing
Graduate of an accredited School of Nursing
Two years of clinical experience plus at least two years in one of the following: Home Health, Utilization/Medical Review, Quality Assurance
Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings
Ability to interpret and apply medical review criteria and clinical guidelines
Proficiency in Microsoft Office and word processing software
Strong analytical, organizational, and decision-making skills
Ability to work independently while managing priorities effectively
Excellent customer service, communication, and critical thinking skills
Ability to handle confidential information with discretion
Preferred
Three years of clinical nursing experience in Home Health, Utilization Review, Medical Review, or Quality Assurance (strongly preferred)
Proficiency in using multiple screens and software programs simultaneously
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