Remote Medical Reviewer (Medicare- Home Health)

The role

The Registered Nurse Medical Reviewer will perform medical review of complex claims, pre-authorization requests, appeals, and fraud and abuse referrals. This 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 and 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 supporting approval or denial of services
• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
• Support quality control activities that advance corporate and team objectives
• Assist with special projects and additional duties as assigned

Required qualifications

• Associate Degree – Nursing, or Graduate of an accredited School of Nursing
• 2 years clinical experience
• Working knowledge of word processing software
• Ability to work independently, prioritize effectively, and make sound decisions
• Good judgment skills
• Demonstrated customer service and organizational skills
• Demonstrated oral and written communication skills
• Analytical or critical thinking skills
• Ability to handle confidential or sensitive information with discretion
• Microsoft Office
• Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)

Nice to have

• Bachelor's degree – Nursing, OR Graduate of an Accredited School of Nursing
• Preferred experience minimum 3 years RN clinical experience
• Knowledge of spreadsheet and database software
• Ability to persuade, negotiate, or influence others
• Working knowledge of managed care and various current forms of health care delivery systems
• Strong clinical experience — home health, rehabilitation, and/or broad medical surgical experience
• Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, system/processing procedures for medical review
• Knowledge of or ability to learn specific criteria/protocol sets and the use of the same
• Working knowledge of Microsoft Excel, Access, or other spreadsheet/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

• Broadway Ventures conducts background checks and drug testing prior to the start of employment
• Some positions may also require fingerprinting
• Candidates must live in and work from an eligible U.S. state
• An AI tool is used to review applications by comparing resumes to requirements

About the company

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