Use your RN experience to review complex medical claims from home while supporting a high-impact federal program.
About Broadway Ventures
Broadway Ventures is an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB) that specializes in program management, technology solutions, and strategic consulting. We partner with government and private sector clients to improve operations, strengthen compliance, and drive sustainable growth.
In this Medical Claims Reviewer role, you’ll support a subcontract with Palmetto GBA, conducting clinical reviews on a wide range of claims. Your expertise will help ensure accurate payment decisions and protect program integrity for the World Trade Center Health Program and related contracts.
Schedule
- Full-time, 40 hours per week
- Monday–Friday, 8:00 AM – 4:30 PM EST
- Remote role with:
- Required access to high-speed, non-satellite internet
- Private, lockable home office space
- Must be able to travel to the Augusta, GA office approximately 4 times per year
- Preferred: candidates living in South Carolina or Georgia
- Strong preference for candidates who live within a designated HUBZone (as defined by SBA)
Responsibilities
- Medical Claims Review
- Conduct pre-pay and post-pay medical claim reviews for services such as radiology, ambulance, physical therapy, and surgical procedures.
- Review medically complex services, prior authorizations, appeals, potential fraud/abuse cases, and coding accuracy.
- Clinical Determinations
- Apply established criteria, protocol sets, and clinical guidelines to determine medical necessity, reasonableness, and coverage.
- Make reasonable charge payment determinations based on clinical/medical documentation.
- Documentation & Rationale
- Clearly document medical rationale to support approvals, denials, or modifications of services and supplies.
- Maintain accurate, compliant records in alignment with contractor and regulatory requirements.
- Education & Support
- Educate internal and external staff on medical review processes, coverage determinations, medical terminology, and coding procedures.
- Provide guidance and input to LPN team members, supporting their development and performance.
- Quality & Collaboration
- Participate in quality control activities to support team and corporate objectives.
- Assist with special projects and specialty assignments as directed by management.
- Contribute to a culture of continuous improvement in utilization review and claims integrity.
Requirements
- Licensure & Education
- Active, unrestricted RN license in the United States and in the state of hire.
- Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
- Bachelor’s degree in Nursing (BSN) from an accredited School of Nursing (required).
- Master’s in Nursing or related field preferred.
- Experience
- Minimum 5 years of clinical RN experience (e.g., medical-surgical, rehabilitation, home health).
- 2–3+ years of experience in utilization review, medical review, quality assurance, or home health.
- Strong clinical foundation with working knowledge of managed care and various healthcare delivery systems.
- Skills & Competencies
- Ability to apply criteria/protocol sets and clinical guidelines for coverage determinations.
- Strong analytical and critical thinking skills with sound clinical judgment.
- Excellent verbal and written communication; ability to educate, persuade, and influence.
- Proven ability to work independently, prioritize effectively, and manage a steady review volume.
- High level of discretion handling confidential and sensitive information.
- Technical Requirements
- Proficiency with Microsoft Office (Word, Excel, Outlook).
- Comfortable using multiple screens and applications simultaneously.
- Reliable high-speed internet with the ability to connect via ethernet cable for secure and stable access.
- Location & Work Authorization
- Remote within a three-hour driving radius of Augusta, GA (30909).
- Strong preference for candidates living year-round in a HUBZone.
- Authorized to work in the United States (no current or future visa sponsorship for this role).
Benefits
- 401(k) with employer matching
- Health, dental, and vision insurance
- Life and disability insurance
- Flexible Spending Account (FSA)
- Paid time off (PTO) and paid holidays
- Fully remote work with periodic, employer-directed travel to Augusta, GA
Step into a high-impact, remote RN role where your clinical judgment directly shapes fair, accurate medical claim outcomes.
Happy Hunting,
~Two Chicks…