Medical Review II (Medicare)

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
• RN Medical Reviewer – Inpatient Rehabilitation Facility (IRF)
• 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:

Reviews all claims subject to medical review in accordance with applicable statute, regulation, CMS guidelines, and coverage requirements.

Conducts pre-claim review (PCR) for IRF services within designated review areas.

Completes complex medical reviews of PCR requests within 2 business days of receipt (including resubmissions).

Completes pre-payment complex medical reviews of Additional Documentation Request (ADR) responses within 30 calendar days of receipt.

Completes post-payment complex medical reviews of ADR responses within 60 calendar days of receipt.

Completes complex medical reviews of reopened ADR responses within 60 calendar days of receipt.

Renders affirmative or non-affirmative determinations on each PCR request, assigning a Unique

Tracking Number (UTN) per billing period; treats incomplete documentation packages as non-affirmed.

Conducts provider phone calls to communicate review determinations and provide education on non-affirmed decisions.

Maintains accurate, timely documentation of all review activity in accordance with contract and CMS requirements.

Minimum Qualifications

• Education Level and Degree Type: Associate Degree – Nursing, or Graduate of an accredited School of Nursing.
• Work Experience: 2 years clinical experience.
• Skills and Abilities: Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Demonstrated customer service and organizational skills.
• Demonstrated oral and written communication skills.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Software and Other Tools: Microsoft Office.
• Licenses and Certificates: Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

Preferred Qualifications

• Education Level and Degree Type: Bachelor's degree – Nursing, OR Graduate of an Accredited School of Nursing.
• Work Experience: Preferred experience minimum 3 years RN clinical experience.
• Skills and Abilities: Knowledge of spreadsheet and database software. Ability to persuade, negotiate, or influence others.
• Working knowledge of managed care and various current forms of health care delivery systems; strong clinical experience — home health, rehabilitation, and/or broad medical surgical experience.
• Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, system/processing procedures for medical review.
• Knowledge of or ability to learn specific criteria/protocol sets and the use of the same.
• Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software.

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.

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