Medical Claims Reviewer (RN)

About this role

<div class="content-intro"><div class="et_pb_module et_pb_text et_pb_text_0 et_pb_text_align_left et_pb_bg_layout_light"> <div class="et_pb_text_inner"> <p style="text-align: justify;">At <strong>Broadway Ventures</strong>, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth. Built on integrity, collaboration, and excellence, we’re more than a service provider—we’re your trusted partner in innovation.</p> </div> </div></div><p><strong>Job Type</strong>: Full-time (40 hours/week)<br><strong>Schedule</strong>: Monday–Friday, 8:00 AM – 5:00 PM</p> <p><strong>Max Salary: W-2 ($60,000-$63,000)</strong></p> <p><strong>Location</strong>: Remote (U.S. – Work from home)<br><strong>Remote Work Requirements</strong>: High-speed internet (non-satellite) and a private, lockable home office<br><strong>Equipment</strong>: You will be provided with all necessary equipment to perform your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.</p> <h3 data-start="383" data-end="407"><strong data-start="387" data-end="405">About the Role</strong></h3> <p data-start="408" data-end="864">We are seeking a dedicated <strong data-start="435" data-end="460">Registered Nurse (RN)</strong> to join our <strong data-start="473" data-end="496">Medical Review team</strong>. This role involves conducting <strong data-start="528" data-end="569">pre- and post-payment medical reviews</strong> to ensure compliance with established clinical criteria and guidelines. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting decisions in accordance with regulatory and organizational requirements.</p> <h3 data-start="866" data-end="896"><strong data-start="870" data-end="894">Key Responsibilities</strong></h3> <ul data-start="897" data-end="1667"> <li data-start="897" data-end="1001">Review <strong data-start="906" data-end="934">medically complex claims</strong>, pre-authorization requests, appeals, and fraud/abuse referrals.</li> <li data-start="1002" data-end="1090">Assess payment determinations using clinical information and established guidelines.</li> <li data-start="1091" data-end="1194">Evaluate <strong data-start="1102" data-end="1160">medical necessity, appropriateness, and reasonableness</strong> for coverage and reimbursement.</li> <li data-start="1195" data-end="1274">Provide clear, well-documented rationales for service approvals or denials.</li> <li data-start="1275" data-end="1397">Educate internal and external teams on <strong data-start="1316" data-end="1394">medical review processes, coverage determinations, and coding requirements</strong>.</li> <li data-start="1398" data-end="1475">Support quality control activities to meet corporate and team objectives.</li> <li data-start="1476" data-end="1585">Provide <strong data-start="1486" data-end="1518">guidance to LPN team members</strong> and support non-clinical staff through training and discussions.</li> <li data-start="1586" data-end="1667">Assist with <strong data-start="1600" data-end="1652">special projects and additional responsibilities</strong> as assigned.</li> </ul> <h3 data-start="1669" data-end="1701"><strong data-start="1673" data-end="1699">Minimum Qualifications</strong></h3> <h4 data-start="1702" data-end="1723"><strong data-start="1707" data-end="1721">Licensure:</strong></h4> <ul data-start="1724" data-end="1895"> <li data-start="1724" data-end="1805">Active, unrestricted RN license in the U.S. and in the state of hire<br data-start="1794" data-end="1797"><strong data-start="1797" data-end="1803">OR</strong></li> <li data-start="1806" data-end="1895">Active <strong data-start="1815" data-end="1848">compact multistate RN license</strong> (as defined by the Nurse Licensure Compact).</li> </ul> <h4 data-start="1897" data-end="1918"><strong data-start="1902" data-end="1916">Education:</strong></h4> <ul data-start="1919" data-end="2008"> <li data-start="1919" data-end="1959">Associate Degree in Nursing<br data-start="1948" data-end="1951"><strong data-start="1951" data-end="1957">OR</strong></li> <li data-start="1960"…