Remote RN Medical Reviewer – Utilization & Claims

BROADWAY VENTURES, LLC; Charleston (SC); Remote; USD 59,000 - 72,000; Full time

Benefits offered by this job

401(k) and company match

PTO that grows with tenure

Health, Vision, Dental

Life Insurance

Disability coverage

Job summary

Broadway Ventures is seeking a Medical Reviewer to evaluate radiology, ambulance, physical therapy, and surgical claims using established criteria and clinical guidelines. This remote role requires an active RN license in the U.S. and an associate degree in nursing.

You will document medical necessity decisions, support claims reviews, and educate staff on review processes. A BSN is preferred, with 5 years of clinical experience and knowledge of Medicare rules.

Qualifications

• RN license active and unrestricted in the U.S. or a multistate license under the NLC.
• Associate’s degree in nursing or equivalent from an accredited school.
• Minimum 2 years clinical experience plus 2 years in utilization or medical review, QA, or home health.

Responsibilities

• Handle a variety of claim types including Radiology, Ambulance, PT and Surgical.
• Use clinical information, Medicare guidelines, and criteria to determine medical necessity and document decisions.
• Review medical claims including complex services, preauthorization or predetermination, appeals, and coding reviews.
• Document rationale for payment/denial of services and supplies.
• Educate internal and external staff on medical review concepts and coverage determinations.
• Provide guidance to LPNs as needed and participate in quality control activities.
• Assist with special projects and specialty assignments as directed by management.

Skills

Written communication

Judgment & critical thinking

Independent work

Confidential information handling

Education

Associate’s degree in nursing

BSN (preferred)

Tools

Microsoft Office

Job description

Broadway Ventures is seeking a Medical Reviewer to evaluate radiology, ambulance, physical therapy, and surgical claims using established criteria and clinical guidelines. This remote role requires an active RN license in the U.S. and an associate degree in nursing.

You will document medical necessity decisions, support claims reviews, and educate staff on review processes. A BSN is preferred, with 5 years of clinical experience and knowledge of Medicare rules.