Medical Claim Reviewer (CGS, DMEC-B)

Broadway Ventures · United States - Remote · Remote

Posted 3/27/2026 · last confirmed live 8/26/2026

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.   Max Salary: W-2 ($65,000/$31.25) Location : Remote (U.S. – Work from home) Remote Work Requirements : High-speed internet (non-satellite) and a private, lockable home office Equipment : 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. About the Role We are seeking a dedicated  Registered Nurse (RN)  to join our  Medical Review team . This role involves conducting  pre- and post-payment medical reviews  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. Key Responsibilities Review  medically complex claims , pre-authorization requests, appeals, and fraud/abuse referrals. Assess payment determinations using clinical information and established guidelines. Evaluate  medical necessity, appropriateness, and reasonableness  for coverage and reimbursement. Provide clear, well-documented rationales for service approvals or denials. Educate internal and external teams on  medical review processes, coverage determinations, and coding requirements . Support quality control activities to meet corporate and team objectives. Provide  guidance to LPN team members  and support non-clinical staff through training and discussions. Assist with  special projects and additional responsibilities  as assigned. Minimum Qualifications Licensure: Active, unrestricted RN license in the U.S. and in the state of hire OR Active  compact multistate RN license  (as defined by the Nurse Licensure Compact). Education: Associate Degree in Nursing OR Graduate of an accredited School of Nursing. Experience: Two years of clinical experience. Skills & Competencies: Strong clinical background in  managed care, home health, rehabilitation, and/or medical-surgical settings . Ability to interpret and apply  medical review criteria and clinical guidelines . Proficiency in  Microsoft Office  and word processing software. Strong  analytical, organizational, and decision-making skills . Ability to work independently while managing priorities effectively. Excellent  customer service, communication, and critical thinking skills . Ability to handle confidential information with discretion.     What to Expect Next: 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. 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. Reasonable accommodations are available for applicants with disabilities. Broadway Ventures utilizes the OFCCP-approved Voluntary Self-Identification of Disability Form (CC-305). The pay range shown is a good-faith estimate of the compensation Broadway Ventures reasonably expects to pay for this position at the time of posting. It is not a guarantee of any particular wage, salary, or total compensation. Actual pay offered depends on job-related factors, which may include skills, experience, education, certifications and licensure, geographic work location, contract funding and budget. For positions covered by the Service Contract Act, pay is also governed by the applicable Department of Labor wage determination, which the government may revise. Some positions are posted in support of a contract proposal that has not yet been awarded. Where that is the case, the position and its final compensation are contingent upon award of the contract to Broadway Ventures and on the terms of the awarded contract, including any government-approved labor rates and the applicable wage determination. Broadway Ventures offers a comprehensive benefits package. A general description of benefits is below. 401(k) and company match PTO that grows the longer you stay Health, Vision, Dental Company provided Life Insurance and Voluntary Life Insurance  Short Term Disability and Long Term Disability    

This role is published by Broadway Ventures on greenhouse. SwiftFit is not the employer and does not accept applications.