Job Description

BROADWAY VENTURES, LLC provided pay range This range is provided by BROADWAY VENTURES, LLC. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more. Base pay range $67,700.00/yr - $67,700.00/yr 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 classified 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. 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 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, view the HUBZone Map . Logistics Full‑time (40 hours/week) Monday‑Friday, 8:00 am – 4:30 pm. Must have high‑speed internet (non‑satellite) and a private, lockable home office. Must be able to travel to the Augusta, GA office occasionally (approximately four times per year). Preferred candidate will live in South Carolina or Georgia. Job Responsibilities Performs medical claim reviews for claims for medically complex services, services requiring pre‑authorization/​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 in 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 health‑care delivery systems; strong clinical experience including 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) 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 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 conduct interviews with the most qualified candidates. We will perform a background check and drug test prior to the start of employment. Equal Opportunity Statement 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. Pay $67,700.00 per year 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 a three‑hour driving radius of Augusta, GA 30909 Seniority level Mid‑Senior level Employment type Full‑time Job function Health Care Provider Industries Hospitals and Health Care #J-18808-Ljbffr BROADWAY VENTURES, LLC

Job Tags

Full time, Contract work, For contractors, Live in, Work at office, Remote work, Work from home, Home office, Monday to Friday, Flexible hours, Shift work,

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