Medical Reviewer (Remote)
About The Position
Registered nurse (RN) Medical Reviewer Location: Remote, U.S. Type: Full-Time Rate: $62-$65K About Broadway Ventures 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. We hire people who bring clinical rigor, sound judgment, and a commitment to doing the work right. Position summary 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 U.S. 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.
- Minimum two years of clinical experience plus at least two years in one of the following: Inpatient/Outpatient settings (i.e. medical-surgical, rehabilitation, SNF, etc..), Utilization/Medical Review, Intensive care (ICU/ER), Quality Assurance
- Familiarity with Medicare Part A/B/HHH guidelines
- Strong clinical background in managed care and/or inpatient/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 priorities effectively.
- Excellent customer service, communication, and critical thinking skills.
- Ability to handle confidential information with discretion.
- Must have lived in the United States for at least 3 out of the last 5 years to pass the required background check.
- A private home office with high-speed, hardwired internet (satellite, hot spots, or Fiber internet. 5G satellite home internet is not permitted due to security protocols).
Nice To Haves
- Three years of clinical nursing experience in Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance.
- Proficiency in using multiple screens and software programs simultaneously.
- Training and experience in ICD coding.
Responsibilities
- 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.
- Assist with special projects and additional responsibilities 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
