Broadway Ventures - Medical Reviewer (Remote)

Remote - USA$129k+3w ago

Remote Senior NA Payments Broadband Associate Physician Microsoft Office Documentation Quality Assurance Fiber Quality Control

Requirements

• Licensure • 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). • Education • Associate Degree in Nursing OR Graduate of an accredited School of Nursing. • 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. • 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. • CMS Residency Rule: Must have lived in the United States for at least 3 out of the last 5 years to pass the required background check. • CMS Residency Rule • Infrastructure: A private home office with high-speed, hardwired internet (satellite, hot spots, or • Infrastructure • Internet: Fiber internet. 5G satellite home internet is not permitted due to security protocols). • Internet • 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.

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.