Medical Claim Reviewer (Remote)

Max Salary: W-2 ($65,000/$31.25)

Location: Remote (U.S. - Work from home)

Remote Work Requirements

• High-speed internet (non-satellite) and a private, lockable home office
• Equipment: You will be provided with all necessary equipment to perform your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.

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. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting decisions in accordance with regulatory and organizational requirements.

Key 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.
• Provide guidance to LPN team members and support non-clinical staff through training and discussions.
• Assist with special projects and additional responsibilities as assigned.

Minimum Qualifications

Licensure

• Active, unrestricted RN license in the U.S. and in the state of hireOR
• Active compact multistate RN license (as defined by the Nurse Licensure Compact).

Education

• Associate Degree in NursingOR
• Graduate of an accredited School of Nursing.

Experience

• Two years of clinical experience.

Skills & Competencies

• 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.

What to Expect Next

• After submitting your application, our recruiting team will review your qualifications.
• This may include a brief telephone interview or email communication to verify resume details and discuss compensation expectations.
• Interviews will be conducted with the most qualified candidates.
• Broadway Ventures conducts background checks and drug testing prior to the start of employment.
• Some positions may also require fingerprinting.

Pay and benefits

The pay range shown is a good-faith estimate of the compensation Broadway Ventures reasonably expects to pay for this position at the time of posting. It is not a guarantee of any particular wage, salary, or total compensation. Actual pay offered depends on job-related factors, which may include skills, experience, education, certifications and licensure, geographic work location, contract funding and budget. For positions covered by the Service Contract Act, pay is also governed by the applicable Department of Labor wage determination, which the government may revise.

Some positions are posted in support of a contract proposal that has not yet been awarded. Where that is the case, the position and its final compensation are contingent upon award of the contract to Broadway Ventures and on the terms of the awarded contract, including any government-approved labor rates and the applicable wage determination.

Broadway Ventures offers a comprehensive benefits package. A general description of benefits is below.

• 401(k) and company match
• PTO that grows the longer you stay
• Health, Vision, Dental
• Company provided Life Insurance and Voluntary Life Insurance
• Short Term Disability and Long Term Disability