Medical Review II (Medicare)

<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>Pay Rate: $62,000-$65,000</strong></p> <p><strong>Location: Remote</strong></p> <p><strong>RN Medical Reviewer – Inpatient Rehabilitation Facility (IRF)</strong></p> <p><strong>Position Summary</strong></p> <p>Broadway Ventures is seeking a licensed Registered Nurse to perform complex medical review of Medicare claims for Inpatient Rehabilitation Facility (IRF) services. This role conducts pre-claim review (PCR) determinations, evaluates Additional Documentation Request (ADR) responses, and communicates determinations directly to providers. Work is production-driven and governed by strict contractual turnaround requirements.</p> <h2><strong>Essential Duties and Responsibilities:</strong></h2> <ul> <li>Reviews all claims subject to medical review in accordance with applicable statute, regulation, CMS guidelines, and coverage requirements.</li> <li>Conducts pre-claim review (PCR) for IRF services within designated review areas.</li> <li>Completes complex medical reviews of PCR requests within 2 business days of receipt (including resubmissions).</li> <li>Completes pre-payment complex medical reviews of Additional Documentation Request (ADR) responses within 30 calendar days of receipt.</li> <li>Completes post-payment complex medical reviews of ADR responses within 60 calendar days of receipt.</li> <li>Completes complex medical reviews of reopened ADR responses within 60 calendar days of receipt.</li> <li>Renders affirmative or non-affirmative determinations on each PCR request, assigning a Unique</li> <li>Tracking Number (UTN) per billing period; treats incomplete documentation packages as non-affirmed.</li> <li>Conducts provider phone calls to communicate review determinations and provide education on non-affirmed decisions.</li> <li>Maintains accurate, timely documentation of all review activity in accordance with contract and CMS requirements.</li> </ul> <h2><strong>Minimum Qualifications</strong></h2> <p><br><strong>Education Level and Degree Type</strong>:</p> <ul> <li> Associate Degree – Nursing, or Graduate of an accredited School of Nursing.</li> </ul> <p><strong>Work Experience</strong>:</p> <ul> <li>2 years clinical experience.</li> </ul> <p><strong>Skills and Abilities</strong>:</p> <ul> <li>Working knowledge of word processing software.</li> <li>Ability to work independently, prioritize effectively, and make sound decisions.</li> <li>Good judgment skills.</li> <li>Demonstrated customer service and organizational skills.</li> <li>Demonstrated oral and written communication skills.</li> <li>Analytical or critical thinking skills.</li> <li>Ability to handle confidential or sensitive information with discretion.</li> <