Medical Review II (Medicare)

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.

Benefits

• 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