Medical Claims Reviewer

Job Description

Job Description

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.

Medical Claims Reviewer Overall Purpose of the Position :

Broadway Ventures has an opening for a Medical Claims Reviewer. Qualified candidates must live within a Hubzone as classifed by SBA.gov. Join our Medical Review team to conduct medical reviews for pre-pay and post-pay claims. This team handles a variety of claim types including Radiology, Ambulance, Physical Therapy and Surgical. Performs medical reviews using clinical / medical information provided by physicians / providers and established criteria / protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. The positions are for a sub-contract with Palmetto GBA.

Worksite :

This is a Work-from-home position. We are classified as a HUBZone small business which means that we ensure a percentage of our workforce lives in a HUBZone (Historically Underutilized Business Zone) while working for Broadway Ventures. We will give a strong preference to applicants who live in a HUBZone year round. To verify whether you live in a HUBZone, you may view the following link : HUBZone Map (sba.gov)

Logistics

• This position is full time (40 hours / week) Monday-Friday, 8 : 00 am – 4 : 30 pm
• This is a work from home position. To work from home, you must have high-speed internet (non-satellite) and a private home office (unshared, lockable office space).
• Must be able to travel to the Augusta, GA office occasionally (approximately 4 times) throughout the year.
• Preferred candidate will live in South Carolina or Georgia.

Job Responsibilities

Performs medical claim reviews for one or more of the following : claims for medically complex services, services that require preauthorization / predetermination, requests for appeal or reconsideration, referrals for potential fraud and / or abuse, and correct coding for claims / operations.

Makes reasonable charge payment determinations based on clinical / medical information and established criteria / protocol sets or clinical guidelines.

Determines medical necessity and appropriateness and / or reasonableness and necessity for coverage and reimbursement.

Documents medical rationale to justify payment or denial of services and / or supplies.

Educates internal / external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.

Participates in quality control activities in support of the corporate and team-based objectives.

Provides guidance, direction, and input as needed to LPN team members.

Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback.

Assists with special projects and specialty duties / responsibilities as assigned by Management.

Minimal Job Qualifications

Required Licenses and Certificates : Active, unrestricted RN licensure from the United States and in the state of hire, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC),

Required Education : Bachelor's degree Nursing, Graduate of accredited School of Nursing.

Required Experience : five years clinical experience two years utilization / medical review, quality assurance, or home health experience.

Required Skills and Abilities : Working knowledge of managed care and various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and / or broad medical surgical experience. Knowledge of specific criteria / protocol sets and the use of the same. 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. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.

Required Software and Tools : Microsoft Office.

Education :

Bachelor's (Required)

Masters (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.

Masters Degree of Nursing or similar is strongly preferred.

Computer proficient to include use of multiple screens and programs simultaneously.

What to Expect Next

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with the most qualified candidates. We will be performing a background check and drug test prior to the start of employment.

Broadway Ventures is an equal opportunity employer and 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 status as a protected veteran.

Benefits :

401(k)

401(k) matching

Dental insurance

Disability insurance

Flexible spending account

Health insurance

Life insurance

Paid time off

Vision insurance

Work from home

Schedule :

8 hour shift

Monday to Friday

Work Location : remote within three hour driving radius of Augusta, GA 30909

What to Expect Next :

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and discuss salary requirements. Management will be conducting interviews with the most qualified candidates. We perform a background and drug test prior to the start of every new hires' employment. In addition, some positions may also require fingerprinting.

Broadway Ventures is an equal-opportunity employer and a VEVRAA Federal Contractor committed to providing a workplace free from harassment and discrimination. We celebrate the unique differences of our employees because they drive curiosity, innovation, and the success of our business. We do not discriminate based on military status, race, religion, color, national origin, gender, age, marital status, veteran status, disability, or any other status protected by the laws or regulations in the locations where we operate. Accommodations are available for applicants with disabilities.