Medical Claim Reviewer (Remote)

The role

A Registered Nurse will conduct pre- and post-payment medical reviews. This role involves assessing medical necessity, appropriateness, and reimbursement eligibility using clinical expertise.

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 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.

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
• Two years of clinical experience
• 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
• High-speed internet (non-satellite)
• Private, lockable home office

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
• Necessary equipment including desktop computer, dual monitors, headset, ethernet cable, and accessories

Before you apply

• Cannot live in California, Colorado, Connecticut, District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, North Dakota, Ohio, Oregon, Rhode Island, Washington State, or
• Broadway Ventures conducts background checks and drug testing prior to the start of employment
• Some positions may require fingerprinting
• An AI tool is used to review applications by comparing resumes to requirements

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.