Remote Home Health RN – 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.

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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.

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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.

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.

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.

Responsibilities

as assigned.

Minimum Qualifications

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 plus at least two years in one of the following: Home Health (meets for both clinical and HH requirement for a total of 2 years) Utilization/Medical Review Quality Assurance 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.

Preferred Qualifications

Three years of clinical nursing experience in Home Health, Utilization Review, Medical Review, or Quality Assurance (strongly preferred). Proficiency in using multiple screens and software programs simultaneously. If you are a detail-oriented RN with a passion for medical review, we encourage you to apply!

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.