Medical Review II (Medicare)

Position Summary

Broadway Ventures is seeking a licensed Registered Nurse to perform complex medical review of Medicare claims for Inpatient Rehabilitation Facility (IRF) services. This role conducts pre-claim review (PCR) determinations, evaluates Additional Documentation Request (ADR) responses, and communicates determinations directly to providers. Work is production-driven and governed by strict contractual turnaround requirements.

Essential Duties and Responsibilities

• Review all claims subject to medical review in accordance with applicable statute, regulation, CMS guidelines, and coverage requirements
• Conduct pre-claim review (PCR) for IRF services within designated review areas
• Complete complex medical reviews of PCR requests within 2 business days of receipt, including resubmissions
• Complete pre-payment complex medical reviews of ADR responses within 30 calendar days of receipt
• Complete post-payment complex medical reviews of ADR responses within 60 calendar days of receipt
• Complete complex medical reviews of reopened ADR responses within 60 calendar days of receipt
• Render affirmative or non-affirmative determinations on each PCR request, assigning a Unique Tracking Number (UTN) per billing period; treat incomplete documentation packages as non-affirmed
• Conduct provider phone calls to communicate review determinations and provide education on non-affirmed decisions
• Maintain accurate, 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; rehabilitation, acute care, or case management background preferred
• Prior experience in Medicare medical review, utilization review, or claims review strongly 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
• Must be authorized to work in the United States without sponsorship

Preferred Qualifications

• Direct experience 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)