<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><div class="jd-section-employer"> <div class="jd-description-text"> <p>Broadway Ventures has an opening for a Medical Reviewer. 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.</p> <h3><strong>Max Salary: W-2 ($65,000/$31.25)</strong></h3> <h3><strong>Worksite:</strong></h3> <p>This is a <strong>Work-from-home </strong>position </p> <p>You must live within a three hour driving radius of Augusta, GA</p> </div> </div> <div class="jd-section-job-taxonomy-attributes"> <p><strong></strong></p> <h3><strong>Key Responsibilities</strong></h3> <ul> <li>Handle a variety of claim types, including Radiology, Ambulance, Physical Therapy, and Surgical.</li> <li>Use clinical information from physicians and providers, Medicare guidelines, and established criteria to determine medical necessity, coverage, and payment, and document each decision.</li> <li>Review medical claims, which may include medically complex services, preauthorization or predetermination requests, appeals and reconsiderations, potential fraud and abuse referrals, and correct coding reviews.</li> <li>Document the medical rationale supporting payment or denial of services and supplies.</li> <li>Educate internal and external staff, including non-medical staff, on medical review, terminology, coverage determinations, and coding.</li> <li>Provide guidance and direction to LPN team members as needed.</li> <li>Take part in quality control activities that support team and corporate objectives.</li> <li>Assist with special projects and specialty assignments as directed by management.</li> </ul> <h3><strong>Minimum Requirements</strong></h3> <ul> <li><strong>License:</strong> Active, unrestricted RN license in the U.S. and in the state of hire, or an active, unrestricted multistate RN license under the Nurse Licensure Compact.</li> <li><strong>Education:</strong> Associate’s degree in nursing or graduate of an accredited school of nursing.</li> <li><strong>Experience:</strong> 2 years of clinical experience plus 2 years in utilization or medical review, quality assurance, or home health.</li> <li><strong>Clinical Background:</strong> Home health, rehabilitation, and/or broad medical-surgical experience.</li> <li><strong>Skills:</strong> Working knowledge of criteria and protocol sets, managed care, and health care delivery systems; proficiency in Microsoft Office; strong written and verbal communication; sound judgment and critical thinking; ability to work independently, prioritize, and handle confidential information.</li> <li><strong>Clearance:</strong> Must be able to pass the CMS background investigation and complete fingerprinting and EUA/system access clearance in a timely manner.</li> </ul> <h3><strong>Preferred Qualifications</strong></h3> <ul> <li>Bachelor of Science in Nursing (BSN)</li> <li>5 years of clinical experience plus 3 years in utilization or medical review, quality assurance, or home health</li> <li>Medicare Part B claims review experience and knowledge of Medicare regulations and policies</li> <li>Experience with spreadsheet and database software</li> </ul> <p><strong></strong></p> </div> <div class="jd-section-job-work-location"> <p class="jd-description-text"> </p> </div><div class="content-conclusion"><p data-start="1731" data-end="1755">What to Expect Next:</p> <p data-start="1757" data-end="2185">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.</p> <p data-start="2187" data-end="2478">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.</p> <p data-start="2480" data-end="2658">Reasonable accommodations are available