Medical Claim Reviewer (Remote)

At Broadway Ventures, 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. Max Salary: W-2 ($65,000/$31.25) Location : Remote (U.S. – Work from home) Remote Work Requirements : High-speed internet (non-satellite) and a private, lockable home office Equipment : 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. About the Role 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. Key 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. Provide guidance to LPN team members and support non-clinical staff through training and discussions. Assist with special projects and additional responsibilities as assigned. Minimum Qualifications 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. Experience Two years of clinical experience. Skills & Competencies Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical 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. 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. AI Hiring Process 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 View email address on click.appcast.io. Making a request will not affect whether you are considered for this position. Broadway Ventures offers a comprehensive benefits package. A general description of benefits is below. 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. Benefits 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 #J-18808-Ljbffr BROADWAY VENTURES, LLC