Happy Money is looking for a dedicated Medical Reviewer (Medicare) to join our Medical Review team. This Registered Nurse (RN) will conduct pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines, upholding our company culture built on integrity, collaboration, and excellence.
What You'll Do
- 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.
- Provide clear, well-documented rationales for service approvals or denials.
- Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.
- Support quality control activities to meet corporate and team objectives.
- Assist with special projects and additional responsibilities as assigned.
What We're Looking For
- Active, unrestricted RN license in the U.S. and in the state of hire OR Active compact multistate RN license (as defined by the Nurse Licensure Compact).
- Associate Degree in Nursing OR Graduate of an accredited School of Nursing.
- Two years of clinical experience plus at least two years in one of the following: Inpatient/Outpatient settings (i.e. medical-surgical, rehabilitation, SNF, etc..), Utilization/Medical Review, Quality Assurance.
- Strong clinical background in managed care and/or inpatient/outpatient settings.
- Ability to interpret and apply medical review criteria and clinical guidelines.
- Proficiency in Microsoft Office and word processing software.
- Strong analytical, organizational, and decision-making skills.
- Ability to work independently while managing priorities effectively.
- Excellent customer service, communication, and critical thinking skills.
- Ability to handle confidential information with discretion.
Nice to Have
- Three years of clinical nursing experience in Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance (strongly preferred).
- Proficiency in using multiple screens and software programs simultaneously.
- Training and experience in ICD coding.
Technical Stack
- Microsoft Office
Work Mode
This is a remote position open to candidates located anywhere in the United States.
Broadway Ventures is an equal opportunity employer.
