Review and determine medical claim eligibility and medical necessity across complex claim types for pre-pay and post-pay evaluations. Ensure compliance with clinical criteria and federal program guidelines for Palmetto GBA.
About Broadway Ventures
Broadway Ventures is an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business delivering program management, advanced technology, and consulting solutions to federal and private-sector partners. We focus on mission-driven execution, operational reliability, and innovation.
Schedule
- Remote
- Monday–Friday, 8:00 AM – 4:30 PM ET
- Must have high-speed wired internet and a private workspace
- Occasional travel to Augusta, GA (approx. 4x/year)
- Preference for candidates in GA or SC
- Must live in or be willing to relocate to a HUBZone
Responsibilities
- Conduct detailed medical claim reviews across radiology, ambulance, physical therapy, and surgical services
- Evaluate requests for appeals, reconsiderations, prior authorization, and fraud risk
- Determine medical necessity and coverage using clinical criteria and guidelines
- Document rationale for approvals or denials with clarity and accuracy
- Educate internal and external staff on review requirements and medical terminology
- Participate in quality programs and support compliance audits
- Provide guidance to LPN team members and assist with special projects
Requirements
- Active, unrestricted RN license (compact licensure required if applicable)
- Bachelor’s degree in Nursing (required); Master’s preferred
- Minimum 5 years of clinical RN experience
- Minimum 2–3 years in medical review, utilization review, quality assurance, or home health
- Strong clinical background (home health, rehab, or med-surg preferred)
- Knowledge of medical necessity criteria, protocols, and coverage guidelines
- Ability to review claims independently and make sound decisions
- Strong written and verbal communication skills
- Proficiency with Microsoft Office and multi-system workflows
- Ability to travel for periodic meetings in Augusta, GA
Benefits
- Medical, dental, vision insurance
- Life and disability insurance
- 401(k) with company match
- Paid time off and holidays
- Work-from-home environment
Happy Hunting,
~Two Chicks…