Clinical Nurse Review

MedRisk LLC • US,

6d • $25 - $50

About The Position

The Clinical Bill Review Nurse is responsible for reviewing medical bills and associated documentation to ensure accuracy, medical necessity, and compliance with workers’ compensation guidelines. This role supports payment integrity by identifying inappropriate charges, ensuring adherence to jurisdictional fee schedules, and applying clinical expertise to support fair and accurate reimbursement.

Requirements

• Active, unrestricted RN license (required)
• Minimum of 3 years of clinical experience
• Strong analytical, communication, and documentation skills

Nice To Haves

• Experience in workers’ compensation or medical bill review strongly preferred
• Familiarity with state-specific workers’ compensation regulations and treatment guidelines
• Experience with bill review platforms (e.g., Strataware, Medata, Mitchell) is a plus

Responsibilities

• Conduct clinical reviews of medical bills to assess medical necessity, appropriateness of care, and alignment with workers’ compensation treatment guidelines.
• Identify billing discrepancies such as unbundling, upcoding, duplicate charges, and non-compensable services.
• Apply jurisdiction-specific fee schedules, utilization review (UR) protocols, and treatment guidelines (e.g., ODG, MTUS).
• Collaborate with bill review analysts, adjusters, and medical providers to clarify clinical information and resolve billing issues.
• Document clinical rationale for recommended payment reductions or denials in accordance with regulatory and client requirements.
• Maintain current knowledge of workers’ compensation regulations, medical coding (ICD, CPT, HCPCS), and clinical best practices.
• Support quality assurance and continuous improvement initiatives within the bill review process.

What This Job Offers

• Career Level: Mid Level