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.

Essential Duties and Responsibilities:

• Reviews all claims subject to medical review in accordance with applicable statutes, regulations, CMS guidelines, and coverage requirements.
• Conducts pre-claim review (PCR) for Inpatient Rehabilitation Facility (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, and treats incomplete documentation packages as non-affirmed.
• Conducts provider phone calls to communicate review determinations and provide education on non-affirmed decisions.
• Maintains accurate and timely documentation of all review activity in accordance with contract and CMS requirements.

Minimum Qualifications:

• Active, unrestricted Registered Nurse (RN) license (compact license preferred).
• Minimum of 2–3 years of clinical nursing experience, with a background in rehabilitation, acute care, or case management preferred.
• Working knowledge of CMS coverage guidelines, IRF medical necessity criteria, and Medicare Administrative Contractor (MAC) review processes.
• Strong analytical and clinical decision-making skills, with the ability to interpret medical records against regulatory criteria.
• Excellent written and verbal communication skills, including experience conveying review determinations directly to providers.
• Proficiency with Microsoft Office and claims/medical review software systems.
• Ability to consistently meet contractual review turnaround deadlines in a production-driven environment.

Preferred Qualifications:

• Experience specifically with Inpatient Rehabilitation Facility (IRF) documentation and CMS Review Choice Demonstration (RCD) programs.
• Certification in case management, utilization review, or a related specialty (e.g., CCM, ACM).
• Minimum of 2–3 years of clinical nursing experience, with rehabilitation, acute care, or case management background preferred.

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.

Broadway Ventures is an equal opportunity employer and a VEVRAA federal contractor. We do not discriminate against applicants or employees on the basis of race, color, religion, sex, national origin, age, disability, protected veteran status, or any other status protected by applicable law.

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