Medical Review II (Medicare)

Job description

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. **Pay Rate: $62,000-$65,000** **Location: Remote** **About Broadway Ventures** Broadway Ventures is a Service-Disabled Veteran-Owned Small Business (SDVOSB) and HUBZone-certified firm headquartered in Vicksburg, Mississippi. We support federal clients across the Centers for Medicare & Medicaid Services (CMS) and the Department of Defense, with a workforce that is approximately 95% remote. **Position Summary** Broadway Ventures is seeking a licensed Registered Nurse to perform complex medical review of Medicare claims for Inpatient Rehabilitation Facility (IRF) services. This role conducts pre-claim review (PCR) determinations, evaluates Additional Documentation Request (ADR) responses, and communicates determinations directly to providers. Work is production-driven and governed by strict contractual turnaround requirements. **Essential Duties and Responsibilities** - Review all claims subject to medical review in accordance with applicable statute, regulation, CMS guidelines, and coverage requirements - Conduct pre-claim review (PCR) for IRF services within designated review areas - Complete complex medical reviews of PCR requests within **2 business days** of receipt, including resubmissions - Complete pre-payment complex medical reviews of ADR responses within **30 calendar days** of receipt - Complete post-payment complex medical reviews of ADR responses within **60 calendar days** of receipt - Complete complex medical reviews of reopened ADR responses within **60 calendar days** of receipt - Render affirmative or non-affirmative determinations on each PCR request, assigning a Unique Tracking Number (UTN) per billing period; treat incomplete documentation packages as non-affirmed - Conduct provider phone calls to communicate review determinations and provide education on non-affirmed decisions - Maintain accurate, timely documentation of all review activity in accordance with contract and CMS requirements **Minimum Qualifications** - Active, unrestricted Registered Nurse (RN) license; compact license preferred - Minimum of 2–3 years of clinical nursing experience; rehabilitation, acute care, or case management background preferred - Prior experience in Medicare medical review, utilization review, or claims review strongly preferred - Working knowledge of CMS coverage guidelines, IRF medical necessity criteria, and Medicare Administrative Contractor (MAC) review processes - Strong analytical and clinical decision-making skills, with the ability to interpret medical records against regulatory criteria - Excellent written and verbal communication skills, including experience conveying review determinations directly to providers - Proficiency with Microsoft Office and claims/medical review software systems - Ability to consistently meet contractual review turnaround deadlines in a production-driven environment - Must be authorized to work in the United States without sponsorship **Preferred Qualifications** - Direct experience with Inpatient Rehabilitation Facility (IRF) documentation and CMS Review Choice Demonstration (RCD) programs - Certification in case management, utilization review, or a related specialty (e.g., CCM, ACM) **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). *The pay range shown is a good-faith estimate of the compensation Broadway Ventures reasonably expects to pay for this position at the time of posting. It is not a guarantee of any particular wage, salary, or total compensation. Actual pay offered depends on job-related factors, which may include skills, experience, education, certifications and licensure, geographic work location, contract funding and budget. For positions covered by the Service Contract Act, pay is also governed by the applicable Department of Labor wage determination, which the government may revise.* *Some positions are posted in support of a contract proposal that has not yet been awarded. Where that is the case, the position and its final compensation are contingent upon award of the contract to Broadway Ventures and on the terms of the awarded contract, including any government-approved labor rates and the applicable wage determination.* *Broadway Ventures offers a comprehensive benefits package. A general description of benefits is below.* - *401(k) and company match* - *PTO that grows the longer you stay* - *Health, Vision, Dental* - *Company provided Life Insurance and Voluntary Life Insurance* - *Short Term Disability and Long Term Disability*