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.

Broadway Ventures has an opening for a Medical Claims Reviewer. This team handles a variety of claim types including Radiology, Ambulance, Physical Therapy and Surgical. Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Max Salary: W-2 ($65,000/$31.25) Worksite: This is a Work-from-home position. Logistics: This position is full time (40 hours/week) Monday-Friday, 8:00 am – 4:30 pm This is a work from home position. To work from home, you must have high-speed internet (non-satellite) and a private home office (unshared, lockable office space). Must be able to travel to the Augusta, GA office occasionally (approximately 4 times) throughout the year. Preferred candidate will live in South Carolina or Georgia.

Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Documents medical rationale to justify payment or denial of services and/or supplies. Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback. Assists with special projects and specialty duties/responsibilities as assigned by Management.