Remote RN Medical Claims Reviewer

BROADWAY VENTURES, LLC; United States; Remote; USD 59,000 - 72,000; Full time

Benefits offered by this job

401(k) match

PTO grows with tenure

Health, Vision, Dental

Life Insurance

Disability

Job summary

Broadway Ventures is seeking a dedicated Registered Nurse (RN) to join our Medical Review team in a remote role. You will conduct pre- and post-payment medical reviews to ensure criteria compliance, assess medical necessity and reimbursement eligibility, and document decisions per regulations.

Ideal candidates have an active RN license in the U.S., two years of clinical experience, and proficiency with MS Office.

Qualifications

• Active, unrestricted RN license in the U.S. and in the state of hire.
• Compact multistate RN license preferred per Nurse Licensure Compact.
• Two years of clinical experience in managed care or related settings.
• Ability to interpret and apply medical review criteria and guidelines.

Responsibilities

• Review medically complex claims, pre-authorization requests, appeals, and referrals.
• Assess payment determinations using clinical information and guidelines.
• Evaluate medical necessity and reasonableness for coverage and reimbursement.
• Provide clear, well-documented rationales for approvals or denials.
• Educate teams on medical review processes and coding requirements.
• Support quality control to meet objectives.
• Provide guidance to LPNs and non-clinical staff through training.
• Assist with special projects as assigned.

Skills

Managed care

Home health

Medical review

Clinical guidelines

MS Office

Analytical skills

Independent work

Communication

Education

Associate Degree in Nursing

Graduate of an accredited School of Nursing

Tools

MS Office

Job description

Broadway Ventures is seeking a dedicated Registered Nurse (RN) to join our Medical Review team in a remote role. You will conduct pre- and post-payment medical reviews to ensure criteria compliance, assess medical necessity and reimbursement eligibility, and document decisions per regulations.

Ideal candidates have an active RN license in the U.S., two years of clinical experience, and proficiency with MS Office.