Medical Claims Reviewer

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.Broadway Ventures has several openings for Medical Claims Reviewer opportunities. Qualified candidates must live within a HUBZone as classified by SBA.gov. Successful candidates will perform medical reviews for durable medical equipment claims. Using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Document decisions using indicated protocol sets or clinical guidelines. Provide support and review of medical claims and utilization practices. There are multiple positions available for a sub-contract with CGS Administrators.Logistics:This is a work from home opportunity. To work from home, you must have high-speed internet (non-satellite) and a private home office.Those living within driving distance of Nashville, TN will work in the Nashville Office.Work hours are 8:00 am to 5:00 pm CT. Monday through Friday.Job Type: Full-time, 40 hours a weekWhat You Will Do: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, 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. Monitors process's timeliness in accordance with contractor standards. 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.What We Require You Have:Required Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact NLC),Required Education: Associates in a job-related field OR graduate of Accredited School of Nursing.Required Work Experience: Two years of clinical nursing experience.Required Skills and Abilities: 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. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.Required Software and Tools: Microsoft Office.What We Prefer You Have:Medicare Part B experience.Medicare DME claims experience is strongly preferred.Intermediate computer experience with the ability to work with multiple Windows 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 qualifies candidates.Pay:$67,700 annual salaryBenefits:401(k)401(k) matchingDental insuranceDisability insuranceFlexible spending accountHealth insuranceLife insurancePaid time offVision insuranceWork from homeWhat 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 qualifies candidates.We perform a background and drug test prior to the start of every new hires' 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.