Broadway Ventures - Medical Claim Reviewer (CGS, DMEC)
Requirements
• Equipment • We are seeking a dedicated Registered Nurse (RN) to join our Medical Review team. This role involves conducting pre- and post-payment medical reviews 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. • Registered Nurse (RN) • Medical Review team • pre- and post-payment medical reviews • Licensure: • Licensure: • Active, unrestricted RN license in the U.S. and in the state of hireOR • Active compact multistate RN license (as defined by the Nurse Licensure Compact). • compact multistate RN license • Education: • Education: • Associate Degree in NursingOR • Graduate of an accredited School of Nursing. • Two years of clinical experience. • Two years • Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings. • managed care, home health, rehabilitation, and/or medical-surgical settings • Ability to interpret and apply medical review criteria and clinical guidelines. • medical review criteria and clinical guidelines • Proficiency in Microsoft Office and word processing software. • Microsoft Office • Strong analytical, organizational, and decision-making skills. • analytical, organizational, and decision-making skills • Ability to work independently while managing priorities effectively. • Excellent customer service, communication, and critical thinking skills. • 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.
Responsibilities
• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals. • medically complex claims • Assess payment determinations using clinical information and established guidelines. • Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement. • medical necessity, appropriateness, and reasonableness • Provide clear, well-documented rationales for service approvals or denials. • Educate internal and external teams on medical review processes, coverage determinations, and coding requirements. • medical review processes, coverage determinations, and coding requirements • Support quality control activities to meet corporate and team objectives. • Provide guidance to LPN team members and support non-clinical staff through training and discussions. • guidance to LPN team members • Assist with special projects and additional responsibilities as assigned.
Benefits
• Location: Remote (U.S. – Work from home)Remote Work Requirements: High-speed internet (non-satellite) and a private, lockable home officeEquipment: 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. • Location
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