Remote RN – Medical Claims Reviewer

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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.

Job Type: Full-time (40 hours/week)
Schedule: Monday–Friday, 8:00 AM – 5:00 PM

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 plus at least two years in one of the following:
    • Home Health
    • 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!

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).

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About United Kingdom

The United Kingdom is an island nation located on the northwest coast of Europe. The United Kingdom includes the entire island of Great Britain, which includes England, Wales, and Scotland, as well as the northern part of the island of Ireland. The name Great Britain is sometimes used to refer to the United Kingdom as a whole. The capital is London, which is one of the business, financial, and cultural centers of the world. Other major cities are Birmingham, Liverpool, and Manchester in England, Belfast and Londonderry in Northern Ireland, Edinburgh and Glasgow in Scotland, and Swansea and Cardiff in Wales.

Common Interview Questions

  • Tell me about yourself.
  • Walk me through your resume.
  • How did you hear about this position?
  • Why do you want to work at this company?
  • Why do you want this job?
  • Why should we hire you?
  • What can you bring to the company?
  • What are your greatest strengths?
  • What do you consider to be your weaknesses?
  • What is your greatest professional achievement?
  • Tell me about a challenge or conflict you’ve faced at work, and how you dealt with it.
  • Tell me about a time you demonstrated leadership skills.
  • What’s a time you disagreed with a decision that was made at work?
  • Tell me about a time you made a mistake.
  • Tell me about a time you failed.
  • Why are you leaving your current job?
  • Why were you fired?
  • Why was there a gap in your employment?
  • Can you explain why you changed career paths?
  • What’s your current salary?
  • What do you like least about your job?
  • What are you looking for in a new position?
  • What type of work environment do you prefer?
  • What’s your work style?
  • What’s your management style?
  • How would your boss and coworkers describe you?
  • How do you deal with pressure or stressful situations?
  • What do you like to do outside of work?
  • Are you planning on having children?
  • How do you stay organized?
  • How do you prioritize your work?
  • What are you passionate about?
  • What motivates you?
  • What are your pet peeves?
  • How do you like to be managed?
  • Do you consider yourself successful?
  • Where do you see yourself in five years?
  • How do you plan to achieve your career goals?
  • What are your career aspirations?
  • What’s your dream job?
  • What other companies are you interviewing with?
  • What makes you unique?
  • What should I know that’s not on your resume?
  • What would your first few months look like in this role?
  • What are your salary expectations?
  • What do you think we could do better or differently?
  • When can you start?
  • Are you willing to relocate?
  • How many tennis balls can you fit into a limousine?
  • If you were an animal, which one would you want to be?
  • Sell me this pen.
  • Is there anything else you’d like us to know?
  • Do you have any questions for us?

Educational Qualification

Candidates Who Have Passed Graduate or its Equivalent from a Recognized Board or University Are Eligible For this recruitment. Kindly check the Official Notification for more qualification details. Notification Link Is Given Below.

Document Required

Required Documents for This recruitment: Candidate should have these documents before applying online. Candidates are suggested to read the official notification before applying.

  • Qualification certificate with mark sheets.
  • Passport size photographs.
  • Signature.

How to Apply

All the eligible candidates can apply for this job as mentioned below:

  • Read official notification carefully from the official website.
  • Read notification carefully before applying.
  • Fill the application form (link is given below).
  • Attach required documents and passport size photo with signature.
  • Then submit. Done.