Broadway Ventures, LLC
Medical Claim Reviewer (CGS, DMEC-B)
United States - Remote · Staff+ · Contract
Sponsorship not specifiedDetected 7 days ago
Customer SupportCommunicationCollaborationCritical ThinkingMicrosoft Office
About the role
- We are seeking a dedicated Registered Nurse (RN) to join our Medical Review team.
- This role involves conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines.
- Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Responsibilities
- Support quality control activities to meet corporate and team objectives.
- Provide guidance to LPN team members and support non-clinical staff through training and discussions.
- As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth.
- Built on integrity, collaboration, and excellence, we're more than a service provider-we're your trusted partner in innovation.
Requirements
- Associate Degree in Nursing OR
Skills
- Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings.
- Ability to interpret and apply medical review criteria and clinical guidelines.
- Proficiency in Microsoft Office and word processing software.
- Strong analytical, organizational, and decision-making skills.
- Ability to work independently while managing priorities effectively.
- Excellent customer service, communication, and critical thinking skills.
- Ability to handle confidential information with discretion.
Compensation
- W-2 ($65,000/$31.25)
Benefits
- Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
- Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
- We do not discriminate against applicants or employees on the basis of race, color, religion, sex, national origin, age, disability, protected veteran status, or any other status protected by applicable law.
- Broadway Ventures utilizes the OFCCP-approved Voluntary Self-Identification of Disability Form (CC-305).
Company info
- At Broadway Ventures, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions.
Equal opportunity
- Broadway Ventures is an equal opportunity employer and a VEVRAA federal contractor.
- equal opportunity employer and a VEVRAA federal contractor.
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