Remote Medical Reviewer - RN (Claims & Utilization)

BROADWAY VENTURES, LLC; Charlotte (NC); Remote; USD 59,000 - 72,000; Full time

Benefits offered by this job

401(k) plan

PTO that grows with tenure

Health, Vision, Dental

Job summary

Broadway Ventures is seeking a Medical Reviewer for a remote role handling various claims (Radiology, Ambulance, Physical Therapy, Surgical). You will apply clinical data and Medicare guidelines to determine medical necessity and payment decisions, documenting rationale clearly.

Minimum requirements include an active RN license in the U.S., an Associate’s degree, and 2+ years in clinical work with utilization/medical review.

Qualifications

• Active RN license in the U.S. and in the state of hire, or an active, unrestricted multistate RN license under the Nurse Licensure Compact.
• Associate’s degree in nursing (required).
• 2 years of clinical experience plus 2 years in utilization or medical review, quality assurance, or home health.
• Home health, rehabilitation, and/or broad medical-surgical experience.
• 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: CMS background investigation, fingerprinting, and EUA/system access clearance.

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, including complex services, preauthorization, appeals, potential fraud referrals, and correct coding reviews.
• Document the medical rationale supporting payment or denial of services and supplies.
• Educate internal and external staff on medical review, terminology, coverage determinations, and coding.
• Provide guidance to LPN team members as needed.
• Participate in quality control activities supporting team and corporate objectives.

Skills

RN license

Clinical experience

Microsoft Office

Communication

Education

Associate's degree in nursing

BSN (preferred)

Job description

Broadway Ventures is seeking a Medical Reviewer for a remote role handling various claims (Radiology, Ambulance, Physical Therapy, Surgical). You will apply clinical data and Medicare guidelines to determine medical necessity and payment decisions, documenting rationale clearly.

Minimum requirements include an active RN license in the U.S., an Associate’s degree, and 2+ years in clinical work with utilization/medical review.