Ethos is hiring a Medical Reviewer (Medicare)

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.