Remote Medical Reviewer (RN) - Claims & Utilization Expert

Broadway Ventures LLC; Oregon; Hybrid; USD 59,000 - 72,000; Full time

Benefits offered by this job

401(k) and company match

PTO grows with tenure

Health, Vision, Dental

Life Insurance

Short/Long Term Disability

Job summary

The Broadway Ventures LLC team is seeking a skilled Medical Reviewer to evaluate a variety of medical claims, including radiology and rehabilitation services. Candidates must hold an active RN license in the United States and an associate degree in nursing.

The role includes working from home within a defined US radius and involves documenting decisions with established criteria. Preferred candidates have BSN and additional clinical and utilization review experience, plus proficiency in MS

Qualifications

• Active, unrestricted RN license in the U.S. and state of hire.
• Associate's degree in nursing or graduate of accredited school.
• 2 years clinical experience plus 2 years in utilization or medical review.
• Home health/rehabilitation experience helpful.
• Strong written and verbal communication; ability to handle confidential info.
• CMS background check, fingerprinting, EUA clearance required.

Responsibilities

• Handle varied claim types (Radiology, Ambulance, PT, Surgical).
• Use physicians’ data, Medicare guidelines to determine medical necessity and payment.
• Review claims including complex services and preauthorizations.
• Document medical rationale for payment/denial.
• Educate staff on medical review concepts and coding.
• Provide guidance to LPNs and participate in QA activities.
• Assist with special projects as directed.

Skills

RN license

Nursing degree

Healthcare knowledge

MS Office

Communication skills

Confidentiality

Independent worker

Education

Associate's degree in nursing

BSN preferred

Tools

MS Office

Job description

The Broadway Ventures LLC team is seeking a skilled Medical Reviewer to evaluate a variety of medical claims, including radiology and rehabilitation services. Candidates must hold an active RN license in the United States and an associate degree in nursing.

The role includes working from home within a defined US radius and involves documenting decisions with established criteria. Preferred candidates have BSN and additional clinical and utilization review experience, plus proficiency in MS