Registered nurse (RN) Medical Reviewer

Location: Remote

Type: Full-Time

Rate: $62-$65K

About Broadway Ventures

Broadway Ventures is a veteran-owned small business (SDVOSB, HUBZone certified) headquartered in Vicksburg, Mississippi, delivering mission-critical support to federal health and defense customers. We hire people who bring clinical rigor, sound judgment, and a commitment to doing the work right.

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 and 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 supporting approval or denial of services
• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
• Support quality control activities that advance corporate and team objectives
• Assist with special projects and additional duties as assigned

Minimum Qualifications

Education Level and Degree Type:

• Associate Degree – Nursing, or Graduate of an accredited School of Nursing.

Work Experience:

• 2 years clinical experience.

Skills and Abilities:

• Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Demonstrated customer service and organizational skills.
• Demonstrated oral and written communication skills.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.

Software and Other Tools:

• Microsoft Office.

Licenses and Certificates:

• Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

Preferred Qualifications

Education Level and Degree Type:

• Bachelor's degree – Nursing, OR Graduate of an Accredited School of Nursing.

Work Experience:

• Preferred experience minimum 3 years RN clinical experience.

Skills and Abilities:

• Knowledge of spreadsheet and database software.
• Ability to persuade, negotiate, or influence others.
• Working knowledge of managed care and various current forms of health care delivery systems; strong clinical experience — home health, rehabilitation, and/or broad medical surgical experience.
• Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, system/processing procedures for medical review. Knowledge of or ability to learn specific criteria/protocol sets and the use of the same.

Software and Other Tools:

Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software