Clinical Reviewer (Utilization Review) (Remote US)

The role

The Clinical Reviewer conducts reviews of home health pre-claim review packages to determine compliance with Medicare criteria. They document outcomes with clinical rationale and engage with providers to clarify documentation.

What you will do

• Conduct comprehensive reviews of home health pre-claim review (PCR) packages to determine compliance with Medicare coverage, coding, and payment criteria.
• Document review outcomes with well-defined clinical rationale in the designated case management system.
• Ensure a turnaround time of within 7 business days.
• Engage with providers to request or clarify documentation.
• Escalate provider concerns or suspected fraud in accordance with established program procedures.
• Maintain a standard of 98% accuracy.
• Fulfill all required training, quality assurance reviews, and inter-rater reliability sessions.

Required qualifications

• Active, unrestricted RN license in state of residence.
• Minimum of 2 years of clinical experience.
• At least 2 years of experience in home health, quality assurance, or utilization review.

Nice to have

• Experience in home health (OASIS, Medicare Conditions of Participation).
• Prior involvement with MAC/RCD/CMS program integrity.
• Proficiency in ICD coding.

Benefits

• 401(k) and company match
• PTO that grows the longer you stay
• Health, Vision, Dental
• Company provided Life Insurance and Voluntary Life Insurance
• Short Term Disability and Long Term Disability

Before you apply

• Broadway Ventures conducts background checks and drug testing prior to the start of employment.
• Some positions may also require fingerprinting.
• Broadway Ventures uses an artificial intelligence (AI) tool to help review applications.
• Some positions are posted in support of a contract proposal that has not yet been awarded.

About the company

Broadway Ventures is an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB) that provides program management, technology, and consulting solutions to government and private sector clients.