[Remote] Medical Reviewer (Medicare)

Note: The job is a remote job and is open to candidates in USA. Broadway Ventures is a government and private sector consulting firm that focuses on transforming challenges into opportunities through innovative solutions. They are seeking a dedicated Registered Nurse (RN) to join their Medical Review team, responsible for conducting medical reviews to ensure compliance with clinical criteria and guidelines. Responsibilities • Review medically complex claims, pre-authorization requests, appeals, and fraud/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 for service approvals or denials • Educate internal and external teams on medical review processes, coverage determinations, and coding requirements • Support quality control activities to meet corporate and team objectives • Assist with special projects and additional responsibilities as assigned Skills • Active, unrestricted RN license in the U.S. and in the state of hire OR Active compact multistate RN license (as defined by the Nurse Licensure Compact) • Associate Degree in Nursing OR Graduate of an accredited School of Nursing • Two years of clinical experience plus at least two years in one of the following: Inpatient/Outpatient settings (i.e. medical-surgical, rehabilitation, SNF, etc..), Utilization/Medical Review, Quality Assurance • Strong clinical background in managed care and/or inpatient/outpatient 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 • Three years of clinical nursing experience in Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance (strongly preferred) • Proficiency in using multiple screens and software programs simultaneously • Training and experience in ICD coding Company Overview • We deliver expert program management, cutting-edge IT, cybersecurity, and consulting solutions for government and commercial clients. It was founded in 2013, and is headquartered in Amite, Louisiana, USA, with a workforce of 51-200 employees. Its website is https://broadwayventures.net. Apply tot his job Apply To this Job