Senior Medical Reviewer

About Broadway Ventures

Broadway Ventures, LLC is a certified small business government contractor providing healthcare administration and IT services to federal agencies, including CMS, the VA, and DoD.

Position Summary

We are seeking an experienced Registered Nurse to directly supervise a team of RN Medical Reviewers supporting Medicare medical review operations. This role owns daily workload distribution and turnaround performance, ensures compliance with CMS and client security requirements, and serves as the first line of escalation for case risk, provider concerns, and integrity matters.

Key Responsibilities

• Directly supervise a team of approximately 20 RN Medical Reviewers, managing day-to-day case assignment and workload distribution
• Monitor case turnaround daily against the 7-business-day requirement, reviewing the case management system to identify cases approaching their due date and rebalancing workload to prevent bottlenecks
• Flag any case at risk of missing turnaround by day 5 of the 7-business-day window, reassigning to a reviewer with capacity or escalating to expedite completion
• Confirm and escalate provider concerns and complaints, suspected fraud, aberrant billing behavior, and data or privacy incidents to the client within required timeframes — one business day, or immediately for fraud and security matters
• Conduct periodic virtual desk audits of assigned RN Medical Reviewers' remote work environments to confirm compliance with CMS and client security and location requirements
• Mentor newly onboarded RN Medical Reviewers on client-furnished systems and procedures once approved for independent production
• Report turnaround performance and workload/staffing risk to the Project Manager daily

Minimum Qualifications

• Active, unrestricted, and unencumbered RN license (single-state or compact multistate)
• ADN or accredited nursing degree (BSN preferred)
• 5+ years of nursing experience, including 2+ years in Medicare medical review or utilization review (UR). Equivalent combinations of clinical and Medicare review experience will be considered.
• Strong documentation and independent decision-making skills, with the ability to oversee a reviewer caseload and workload distribution under strict deadlines
• Must reside and work from within the U.S., D.C., or a U.S. territory
• Private, secure home workspace meeting CMS security requirements

Preferred Qualifications

• Direct home health RCD or comparable MAC medical review experience
• Existing familiarity with home health pre-claim review documentation, including face-to-face encounter notes, comprehensive assessments, plans of care, certifications and recertifications, and homebound/medical necessity documentation
• Prior MAC, RCD, or CMS program integrity experience across multiple jurisdictions (e.g., Jurisdiction J/M)