<div class="content-intro"><div class="et_pb_module et_pb_text et_pb_text_0 et_pb_text_align_left et_pb_bg_layout_light"><div class="et_pb_text_inner"><p style="text-align: justify;">At <strong>Broadway Ventures</strong>, 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.</p></div></div></div><p><strong>Job Type</strong>: Full-time (40 hours/week)<br><strong>Schedule</strong>: Monday–Friday, 8:00 AM – 5:00 PM<br><strong>Location</strong>: Remote (U.S. – Work from home)<br><strong>Remote Work Requirements</strong>: High-speed internet (non-satellite) and a private, lockable home office<br><strong>Equipment</strong>: 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.</p><h3 data-start="383" data-end="407"><strong data-start="387" data-end="405">About the Role</strong></h3><p data-start="408" data-end="864">We are seeking a dedicated <strong data-start="435" data-end="460">Registered Nurse (RN)</strong> to join our <strong data-start="473" data-end="496">Medical Review team</strong>. This role involves conducting <strong data-start="528" data-end="569">pre- and post-payment medical reviews</strong> 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.</p><h3 data-start="866" data-end="896"><strong data-start="870" data-end="894">Key Responsibilities</strong></h3><ul data-start="897" data-end="1667"><li data-start="897" data-end="1001">Review <strong data-start="906" data-end="934">medically complex claims</strong>, pre-authorization requests, appeals, and fraud/abuse referrals.</li><li data-start="1002" data-end="1090">Assess payment determinations using clinical information and established guidelines.</li><li data-start="1091" data-end="1194">Evaluate <strong data-start="1102" data-end="1160">medical necessity, appropriateness, and reasonableness</strong> for coverage and reimbursement.</li><li data-start="1195" data-end="1274">Provide clear, well-documented rationales for service approvals or denials.</li><li data-start="1275" data-end="1397">Educate internal and external teams on <strong data-start="1316" data-end="1394">medical review processes, coverage determinations, and coding requirements</strong>.</li><li data-start="1398" data-end="1475">Support quality control activities to meet corporate and team objectives.</li><li data-start="1476" data-end="1585">Provide <strong data-start="1486" data-end="1518">guidance to LPN team members</strong> and support non-clinical staff through training and discussions.</li><li data-start="1586" data-end="1667">Assist with <strong data-start="1600" data-end="1652">special projects and additional responsibilities</strong> as assigned.</li></ul><h3 data-start="1669" data-end="1701"><strong data-start="1673" data-end="1699">Minimum Qualifications</strong></h3><h4 data-start="1702" data-end="1723"><strong data-start="1707" data-end="1721">Licensure:</strong></h4><ul data-start="1724" data-end="1895"><li data-start="1724" data-end="1805">Active, unrestricted RN license in the U.S. and in the state of hire<br data-start="1794" data-end="1797"><strong data-start="1797" data-end="1803">OR</strong></li><li data-start="1806" data-end="1895">Active <strong data-start="1815" data-end="1848">compact multistate RN license</strong> (as defined by the Nurse Licensure Compact).</li></ul><h4 data-start="1897" data-end="1918"><strong data-start="1902" data-end="1916">Education:</strong></h4><ul data-start="1919" data-end="2008"><li data-start="1919" data-end="1959">Associate Degree in Nursing<br data-start="1948" data-end="1951"><strong data-start="1951" data-end="1957">OR</strong></li><li data-start="1960" data-end="2008">Graduate of an accredited School of Nursing.</li></ul><h4 data-start="2010" data-end="2032"><strong data-start="2015" data-end="2030">Experience:</strong></h4><ul data-start="2033" data-end="2217"><li data-start="2033" data-end="2217"><strong data-start="2035" data-end="2048">Two years</strong> of clinical experience <strong data-start="2072" data-end="2080">plus</strong> at least <strong data-start="2090" data-end="2103">two years</strong> in one of the following:<ul data-start="2133" data-end="2217"><li data-start="2133" data-end="2167"><strong data-start="2135" data-end="2165">Home Health</strong></li><li data-start="2133" data-end="2167"><strong data-start="2135" data-end="2165">Utilization/Medical Review</strong></li><li data-start="2170" data-end="2195"><strong data-start="2172" data-end="2193">Quality Assurance</strong></li></ul></li></ul><h4 data-start="2219" data-end="2252"><strong data-start="2224" data-end="2250">Skills & Competencies:</strong></h4><ul data-start="2253" data-end="2814"><li data-start="2253" data-end="2367">Strong clinical background in <strong data-start="2285" data-end="2364">managed care, home health, rehabilitation, and/or medical-surgical settings</strong>.</li><li data-start="2368" data-end="2455">Ability to interpret and apply <strong data-start="2401" data-end="2452">medical review criteria and clinical guidelines</strong>.</li><li data-start="2456" data-end="2525">Proficiency in <strong data-start="2473" data-end="2493">Microsoft Office</strong> and word processing software.</li><li data-start="2526" data-end="2596">Strong <strong data-start="2535" data-end="2593">analytical, organizational, and decision-making skills</strong>.</li><li data-start="2597" data-end="2669">Ability to work independently while managing priorities effectively.</li><li data-start="2670" data-end="2750">Excellent <strong data-start="2682" data-end="2747">customer service, communication, and critical thinking skills</strong>.</li><li data-start="2751" data-end="2814">Ability to handle confidential information with discretion.</li></ul><h3 data-start="2816" data-end="2850"><strong data-start="2820" data-end="2848">Preferred Qualifications</strong></h3><ul data-start="2851" data-end="3080"><li data-start="2851" data-end="3000"><strong data-start="2853" data-end="2868">Three years</strong> of clinical nursing experience in <strong data-start="2903" data-end="2976">Home Health, Utilization Review, Medical Review, or Quality Assurance</strong> (strongly preferred).</li><li data-start="3001" data-end="3080">Proficiency in using multiple screens and software programs simultaneously.</li></ul><p data-start="3082" data-end="3177">If you are a detail-oriented RN with a passion for medical review, we encourage you to apply!</p><div class="content-conclusion"><p><strong>What to Expect Next:</strong></p><p>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.</p><p>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.</p></div>