Remote Medical Reviewer (Medicare- Home Health)
Broadway Ventures
•$62,000 - $65,000•Remote
About The Position
We are seeking an experienced Registered Nurse to perform medical review of complex claims, pre-authorization requests, appeals, and fraud and abuse referrals. In this role you will apply clinical expertise and established coverage guidelines to determine medical necessity and support accurate payment determinations.
Requirements
- Active, unrestricted RN license in the United States and in the state of hire, or Active compact multistate RN license as defined by the Nurse Licensure Compact
- Associate Degree in Nursing, or Graduate of an accredited School of Nursing
- Two years of clinical experience, plus at least two years in one of the following: Inpatient or outpatient settings (for example, medical-surgical, rehabilitation, skilled nursing facility), Utilization or medical review, Quality assurance
- Strong clinical background in managed care and/or inpatient and 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 competing priorities
- Excellent customer service, communication, and critical thinking skills
- Ability to handle confidential information with discretion
Responsibilities
- 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
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
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
