Medical Reviewer (Remote)

The role

The Medical Reviewer performs medical reviews using clinical information and established criteria. This person handles various claim types and provides support for medical claims and utilization practices.

What you will do

• Handle a variety of claim types, including Radiology, Ambulance, Physical Therapy, and Surgical.
• Use clinical information from physicians and providers, Medicare guidelines, and established criteria to determine medical necessity, coverage, and payment.
• Document each decision.
• Review medical claims including medically complex services, preauthorization, predetermination requests, appeals, reconsiderations, potential fraud and abuse referrals, and correct coding reviews.
• Document the medical rationale supporting payment or denial of services and supplies.
• Educate internal and external staff on medical review, terminology, coverage determinations, and coding.
• Provide guidance and direction to LPN team members as needed.
• Take part in quality control activities.
• Assist with special projects and specialty assignments as directed by management.

Required qualifications

• Active, unrestricted RN license in the U.S. and in the state of hire, or an active, unrestricted multistate RN license under the Nurse Licensure Compact.
• Associate’s degree in nursing or graduate of an accredited school of nursing.
• 2 years of clinical experience plus 2 years in utilization or medical review, quality assurance, or home health.
• Home health, rehabilitation, and/or broad medical-surgical experience.
• Working knowledge of criteria and protocol sets, managed care, and health care delivery systems.
• Proficiency in Microsoft Office.
• Strong written and verbal communication.
• Sound judgment and critical thinking.
• Ability to work independently, prioritize, and handle confidential information.
• Must be able to pass the CMS background investigation and complete fingerprinting and EUA/system access clearance in a timely manner.

Nice to have

• Bachelor of Science in Nursing (BSN)
• 5 years of clinical experience plus 3 years in utilization or medical review, quality assurance, or home health
• Medicare Part B claims review experience and knowledge of Medicare regulations and policies
• Experience with spreadsheet and database software

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 live within a three hour driving radius of Augusta, GA
• Cannot live in California, Colorado, Connecticut, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, North Dakota, Ohio, Oregon, Rhode Island, Washington State,
• Must be able to pass the CMS background investigation and complete fingerprinting and EUA/system access clearance.
• Broadway Ventures conducts background checks and drug testing prior to the start of employment.
• 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.