Medical Claim Reviewer (CGS, DMEC-B)

At Broadway Ventures , we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. 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. 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 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: 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. Broadway Ventures is an equal opportunity employer and a VEVRAA federal contractor. 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. Reasonable accommodations are available for applicants with disabilities. Broadway Ventures utilizes the OFCCP-approved Voluntary Self-Identification of Disability Form (CC-305).