Remote Nursing Jobs · Managed Care

• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
• Assess payment determinations using clinical information and established guidelines.
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.

Broadway Ventures transforms 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), they empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth.

• Provide case management to members including medical, social, psychological, physical, and spiritual needs.
• Develop, implement, and monitor the care plan in conjunction with the PCP, caregivers, and other team members.
• Help meet the member's needs.

Elderplan and HomeFirst are Medicare and Medicaid managed care health plans that are expanding services in response to patients' needs. At MJHS, they are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services.

• Provides telephonic assessments of members’ medical, psychosocial, physical, and spiritual needs.
• Develops a Person-Centered Service Plan (PCSP) utilizing UAS-NY assessments.
• Revises the PCSP and communicates changes with interdisciplinary care team and PCP in response to changes in members’ condition.

MJHS provides high-quality, personalized health care services. At MJHS, they foster collaboration, celebrate achievements, and promote fairness.