Remote Medical Reviewer (Medicare- Home Health)
- Experience
- Mid
- Employment
- Full-time
Open to US only. Set where you work from to check your eligibility.
No BS summary
An experienced RN (active US or compact license) to do Medicare/home-health medical review of claims, pre-auth requests, appeals, and fraud/abuse referrals remotely. Requires 2+ years of clinical experience plus at least 2 more years in inpatient/outpatient, utilization/medical review, or quality assurance. US-only hiring, roughly $62–$65K a year.
Required skills
At Broadway Ventures , 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. Registered nurse (RN) Medical Reviewer Location: Remote 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. Key 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 Minimum qualifications Licensure 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 Education Associate Degree in Nursing, or Graduate of an accredited School of Nursing Experience 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 Skills and competencies 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 What to Expect Next: After submitting your application, our recruiting team will review your qualifications. This may include a brief telephone interview or email communication to verify resume details and discuss compensation expectations. Interviews will be conducted with the most qualified candidates. Broadway Ventures conducts background checks and drug testing prior to the start of employment. Some positions may also require fingerprinting. Broadway Ventures is an equal opportunity employer and a VEVRAA federal contractor. We do not discriminate against applicants or employees on the basis of race, color, religion, sex, national origin, age, disability, protected veteran status, or any other status protected by applicable law. Reasonable accommodations are available for applicants with disabilities. Broadway Ventures utilizes the OFCCP-approved Voluntary Self-Identification of Disability Form (CC-305). The pay range shown is a good-faith estimate of the compensation Broadway Ventures reasonably expects to pay for this position at the time of posting. It is not a guarantee of any particular wage, salary, or total compensation. Actual pay offered depends on job-related factors, which may include skills, experience, education, certifications and licensure, geographic work location, contract funding and budget. For positions covered by the Service Contract Act, pay is also governed by the applicable Department of Labor wage determination, which the government may revise. Some positions are posted in support of a contract proposal that has not yet been awarded. Where that is the case, the position and its final compensation are contingent upon award of the contract to Broadway Ventures and on the terms of the awarded contract, including any government-approved labor rates and the applicable wage determination. Broadway Ventures offers a comprehensive benefits package. A general description of benefits is below. 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
What you'll 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
What they require
- 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
- At least two years in inpatient or outpatient settings (e.g., medical-surgical, rehabilitation, skilled nursing facility), utilization or medical review, or 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
- Excellent customer service, communication, and critical thinking skills
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
Broadway Ventures transforms challenges into opportunities with expert program management, technology, and consulting solutions for government and private sector clients. It is an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB).