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Position Summary:
- Experienced RN performing medical review of complex claims and pre-authorization requests.
- Apply clinical expertise and coverage guidelines to determine medical necessity.
Key Responsibilities:
- Review claims, appeals, and fraud/abuse referrals.
- Document rationales and educate teams on coverage determinations.
Minimum Qualifications:
- Active U.S. RN license or compact multistate license.
- Two years of clinical experience plus two years in utilization review.
- Microsoft Office and strong analytical skills.
Broadway Ventures
Broadway Ventures is a veteran-owned small business delivering mission-critical support to federal health and defense customers. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it is built on integrity, collaboration, and excellence.