Remote Medical Reviewer (Medicare- Home Health)

<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>Registered nurse (RN) Medical Reviewer</strong></p> <p><strong>Location: </strong>Remote</p> <p><strong>Type:</strong> Full-Time</p> <p><strong>Rate:</strong> $62-$65K</p> <p><strong>About Broadway Ventures</strong></p> <p>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.</p> <p><strong>Position summary</strong></p> <p>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.</p> <p><strong>Key responsibilities</strong></p> <ul> <li>Review medically complex claims, pre-authorization requests, appeals, and fraud and abuse referrals</li> <li>Assess payment determinations using clinical information and established guidelines</li> <li>Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement</li> <li>Provide clear, well-documented rationales supporting approval or denial of services</li> <li>Educate internal and external teams on medical review processes, coverage determinations, and coding requirements</li> <li>Support quality control activities that advance corporate and team objectives</li> <li>Assist with special projects and additional duties as assigned</li> </ul> <p><strong>Minimum qualifications</strong></p> <p><strong>Licensure</strong></p> <ul> <li>Active, unrestricted RN license in the United States and in the state of hire, <strong>or</strong></li> <li>Active compact multistate RN license as defined by the Nurse Licensure Compact</li> </ul> <p><strong>Education</strong></p> <ul> <li>Associate Degree in Nursing, <strong>or</strong></li> <li>Graduate of an accredited School of Nursing</li> </ul> <p><strong>Experience</strong></p> <ul> <li>Two years of clinical experience, <strong>plus</strong> at least two years in one of the following:</li> <ul> <li>Inpatient or outpatient settings (for example, medical-surgical, rehabilitation, skilled nursing facility)</li> <li>Utilization or medical review</li> <li>Quality assurance</li> </ul> </ul> <p><strong>Skills and competencies</strong></p> <ul> <li>Strong clinical background in managed care and/or inpatient and outpatient settings</li> <li>Ability