Medical Reviewer (Remote)

Registered nurse (RN) Medical Reviewer

Location: Remote, U.S.

Type: Full-Time

Rate: $62-$65K

Position summary

We are seeking an experienced Registered Nurse to perform medical review of complex claims, pre-authorization requests, appeals, and fraud and abuse referrals. In this role you will apply clinical expertise and established coverage guidelines to determine medical necessity and support accurate payment determinations.

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. 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 hire OR Active compact multistate RN license (as defined by the Nurse Licensure Compact).

Education

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

Experience

• Minimum 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 Intensive care (ICU/ER)
• Quality Assurance Familiarity with Medicare Part A/B/HHH guidelines

Skills & Competencies

• 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.

Preferred Qualifications

• Three years of clinical nursing experience in Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance.
• Proficiency in using multiple screens and software programs simultaneously.
• Training and experience in ICD coding.

Remote & Logistics Requirements

• CMS Residency Rule: Must have lived in the United States for at least 3 out of the last 5 years to pass the required background check.
• Infrastructure: A private home office with high-speed, hardwired internet (satellite, hot spots, or
• Internet: Fiber internet. 5G satellite home internet is not permitted due to security protocols).

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