Medical Reviewer

Key Responsibilities

• Handle a variety of claim types, including Radiology, Ambulance, Physical Therapy, and Surgical.
• Use clinical information from physicians and providers, Medicare guidelines, and established criteria to determine medical necessity, coverage, and payment, and document each decision.
• Review medical claims, which may include medically complex services, preauthorization or predetermination requests, appeals and reconsiderations, potential fraud and abuse referrals, and correct coding reviews.
• Document the medical rationale supporting payment or denial of services and supplies.
• Educate internal and external staff, including non-medical staff, on medical review, terminology, coverage determinations, and coding.
• Provide guidance and direction to LPN team members as needed.
• Take part in quality control activities that support team and corporate objectives.
• Assist with special projects and specialty assignments as directed by management.

Minimum Requirements

• License: Active, unrestricted RN license in the U.S. and in the state of hire, or an active, unrestricted multistate RN license under the Nurse Licensure Compact.
• Education: Associate’s degree in nursing or graduate of an accredited school of nursing.
• Experience: 2 years of clinical experience plus 2 years in utilization or medical review, quality assurance, or home health.
• Clinical Background: Home health, rehabilitation, and/or broad medical-surgical experience.
• Skills: Working knowledge of criteria and protocol sets, managed care, and health care delivery systems; proficiency in Microsoft Office; strong written and verbal communication; sound judgment and critical thinking; ability to work independently, prioritize, and handle confidential information.
• Clearance: Must be able to pass the CMS background investigation and complete fingerprinting and EUA/system access clearance in a timely manner.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN)
• 5 years of clinical experience plus 3 years in utilization or medical review, quality assurance, or home health
• Medicare Part B claims review experience and knowledge of Medicare regulations and policies
• Experience with spreadsheet and database software

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.

Location Eligibility: Broadway Ventures cannot consider applicants who live in, or would work from, any of the following locations: California, Colorado, Connecticut, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, North Dakota, Ohio, Oregon, Rhode Island, Washington State, and Wyoming. Candidates must live in and work from an eligible U.S. state when they are hired and for as long as they are employed. Applications from residents of the locations listed above will not be considered.

Notice: Use of Artificial Intelligence in Our Hiring Process

Broadway Ventures uses an artificial intelligence (AI) tool to help review applications for this position.

• Who built it: Broadway Ventures developed the tool in-house.
• What it does: It compares your resume to the requirements in this job posting and gives a score from 0 to 100 showing how closely your qualifications match.
• What information it uses: The text of your resume, your name, your current or most recent job title, your location, and this job posting.
• What it cannot see: Your answers to voluntary demographic or equal employment opportunity questions, interview feedback, or offer information.
• How it is used: The score is one factor in our initial review of applications. The tool does not reject anyone. A member of our recruiting team reviews every application before any decision is made.
• Your options: If you would like your application reviewed without the AI tool, or you need a reasonable accommodation at any point in the hiring process, contact us at recruiting@broadwayventures.net. Making a request will not affect whether you are considered for this position.

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