Remote RN Medical Reviewer: Claims & Compliance

Broadway Ventures LLC; Oregon; Hybrid; USD 62,000 - 65,000; Full time

Benefits offered by this job

401(k) and company match

PTO that grows the longer you stay

Health, Vision, Dental

Life Insurance

Short Term Disability

Job summary

Broadway Ventures LLC is seeking an experienced Registered Nurse to perform medical review of complex claims, pre-authorization requests, appeals, and fraud and abuse referrals. You will apply clinical expertise and established coverage guidelines to determine medical necessity and support accurate payment determinations.

You will educate internal and external teams on medical review processes, coverage determinations, and coding requirements, and support quality control activities and special

Qualifications

• Associate degree in nursing or graduate of an accredited School of Nursing.
• Minimum 2 years of clinical experience.
• Active RN licensure in state hired or compact multistate license.
• Knowledge of Medicare regulations and home health, rehab, or medical-surgical care.

Responsibilities

• Review medically complex claims, pre-authorization requests, appeals, and fraud and abuse referrals.
• Assess payment determinations using clinical information and guidelines.
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
• Provide clear, well-documented rationales supporting approvals or denials.

Skills

Independent work

Communication skills

Analytical thinking

Discretion

Customer service

Education

Associate Degree - Nursing

Bachelor1s degree - Nursing

Tools

Microsoft Office

Microsoft Excel

Microsoft Access

Job description

Broadway Ventures LLC is seeking an experienced Registered Nurse to perform medical review of complex claims, pre-authorization requests, appeals, and fraud and abuse referrals. You will apply clinical expertise and established coverage guidelines to determine medical necessity and support accurate payment determinations.

You will educate internal and external teams on medical review processes, coverage determinations, and coding requirements, and support quality control activities and special