Medical Reviewer (Remote)

Broadway Ventures

1d•Remote

About The Position

Broadway Ventures has an opening for a Medical Reviewer. This team handles a variety of claim types including Radiology, Ambulance, Physical Therapy and Surgical. Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.

Requirements

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 Haves

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

Responsibilities

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, and document each decision.
Review medical claims, which may include medically complex services, preauthorization or predetermination requests, appeals and 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, including non-medical 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 that support team and corporate objectives.
Assist with special projects and specialty assignments as directed by management.