Medical Reviewer (Remote)

The role

An experienced Registered Nurse will perform medical review of complex claims, pre-authorization requests, appeals, and fraud and abuse referrals. The role involves applying clinical expertise and coverage guidelines to determine medical necessity and support payment determinations.

What you will do

• 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.
• Assist with special projects and additional responsibilities as assigned.

Required qualifications

• Active, unrestricted RN license in the U.S. and in the state of hire OR Active compact multistate RN license
• Associate Degree in Nursing OR Graduate of an accredited School of Nursing
• Minimum two years of clinical experience
• At least two years in Inpatient/Outpatient settings, Utilization/Medical Review, Intensive care (ICU/ER), or Quality Assurance
• Familiarity with Medicare Part A/B/HHH guidelines
• Strong clinical background in managed care and/or inpatient/outpatient 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

Nice to have

• Three years of clinical nursing experience in Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance
• Proficiency in using multiple screens and software programs simultaneously
• Training and experience 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

• Must have lived in the United States for at least 3 out of the last 5 years
• Requires a private home office with high-speed, hardwired fiber internet
• Broadway Ventures conducts background checks and drug testing
• Some positions may require fingerprinting

About the company

Broadway Ventures is a veteran-owned small business (SDVOSB, HUBZone certified) headquartered in Vicksburg, Mississippi. They deliver mission-critical support to federal health and defense customers.