Job Description

Overview Broadway Ventures, an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), delivers program management, technology, and innovative consulting solutions for government and private sector clients. We are committed to integrity, collaboration, and excellence, and we aim to drive operational success, sustainability, and growth for our partners. Medical Claims Reviewer Broadway Ventures has an opening for a Medical Claims Reviewer. Qualified candidates must live within a HUBZone as classified by SBA.gov. Join our Medical Review team to conduct medical reviews for pre-pay and post-pay claims, handling claim types including Radiology, Ambulance, Physical Therapy, and Surgical. Reviews are performed using clinical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines, with documentation of decisions. This is a subcontracted position with Palmetto GBA and is work-from-home. We give strong preference to applicants who live in a HUBZone year-round. To verify HUBZone status, refer to the HUBZone Map (sba.gov). Logistics Full-time (40 hours/week), Monday–Friday, 8:00 am – 4:30 pm Work from home; requires high-speed internet (non-satellite) and a private, lockable home office space Occasional travel to the Augusta, GA office (approximately 4 times per year) Preferred candidate will reside in South Carolina or Georgia Job Responsibilities Performs medical claim reviews for: medically complex services, preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations Determines payment amounts based on clinical information and established criteria/protocols Assesses medical necessity and reasonableness for coverage and reimbursement Documents medical rationale to justify payment or denial of services and/or supplies Educates internal/external staff on medical reviews, terminology, coverage determinations, coding procedures, etc., in accordance with contractor guidelines Participates in quality control activities supporting corporate and team objectives Provides guidance to LPN team members and education to non-medical staff as needed Assists with special projects and specialty duties as assigned by Management Minimum Job Qualifications Licenses and Certificates: Active, unrestricted RN licensure in the state of hire; active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) Education: Bachelor’s degree in Nursing; graduate of an accredited School of Nursing Experience: Five years clinical nursing experience; two years utilization/medical review, quality assurance, or home health experience Skills and Abilities: Knowledge of managed care and healthcare delivery systems; strong clinical experience (home health, rehabilitation, and/or broad medical-surgical). Proficiency with Microsoft Office. Ability to work independently, prioritize, and make sound decisions. Strong judgment, customer service, organizational, and communication skills. Ability to handle confidential information Software and Tools: Microsoft Office Education & Experience Education: Bachelor’s degree required; Master’s preferred Experience: Utilization/Medical Review, Quality Assurance or Home Health: 3 years (Required); Clinical RN: 5 years (Required) License/Certification: RN License (Required) Preferred Job Qualifications Five years of clinical nursing experience in Home Health, Utilization or Medical Review or Quality Assurance Master’s Degree of Nursing or similar preferred Computer proficiency with multiple screens and programs What to Expect Next After submitting your application, our recruiting team will review your resume to verify qualifications. This may include a brief telephone interview or email communication with a recruiter. Management will interview the most qualified candidates. A background check and drug test are performed prior to start of employment. Equal Opportunity & Compliance Broadway Ventures is an equal opportunity employer and a VEVRAA Federal Contractor. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. Compensation & Benefits Pay: $67,700 per year 401(k) and 401(k) matching Disability insurance Flexible spending account Health insurance Life insurance Paid time off Vision insurance Work from home Schedule Eight-hour shifts, Monday–Friday Work Location Remote within a three-hour driving radius of Augusta, GA 30909 Self-Identification Voluntary self-identification of disability and veteran status information is requested for equal employment opportunity reporting. Completion is voluntary; information is confidential and will not affect hiring decisions. See the full notice in the job posting for details. #J-18808-Ljbffr Broadway Ventures LLC

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