Remote RN Medical Reviewer: Claims & Coverage Expert

BROADWAY VENTURES, LLC; United States; A distancia; USD 62.000 - 65.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

401(k) with company match

PTO that grows with tenure

Health, Vision, Dental

Life Insurance

Disability insurance

Descripción de la vacante

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

We offer a remote, full-time position with competitive pay and benefits. Active RN licensure in the state hired is required, with a preference for a BSN.

Formación

• Associate Degree in Nursing or graduate from accredited School of Nursing.
• Minimum 2 years clinical nursing experience.
• Active RN licensure in state hired or active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
• Preferred: Bachelor's degree in Nursing or graduate of an Accredited School of Nursing.

Responsabilidades

• Review medically complex claims, pre-authorization requests, appeals, and fraud and 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 supporting approval or denial of services.
• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
• Support quality control activities that advance corporate and team objectives.
• Assist with special projects and additional duties as assigned.

Conocimientos

Analytical thinking

Communication skills

Organizational skills

Independent work

Customer service

Educación

Associate Degree – Nursing

Bachelor's degree – Nursing

Herramientas

Microsoft Office

Excel

Access

Descripción del empleo

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

We offer a remote, full-time position with competitive pay and benefits. Active RN licensure in the state hired is required, with a preference for a BSN.