Who We Are
We're a group of talented, driven professionals who strive every day to improve the lives of our clients, our providers and the ultimate stakeholders - the injured workers. We offer an exciting workplace environment plus competitive salaries and benefits. What makes us stand out? It's the people, the culture we foster and the opportunity to learn and to grow.
Job Summary
The Clinical Bill Review Nurse/ Certified Coder 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/ coding expertise to support fair and accurate reimbursement.
Primary Duties & Responsibilities
• Conduct clinical/ coding 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/ coding information and resolve billing issues. • Document clinical/ coding 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/ coding best practices. • Support quality assurance and continuous improvement initiatives within the bill review process.
Qualifications
Active, unrestricted professional nursing license OR Certified Coder with inpatient/ outpatient coding specialization/ experience.
Minimum of 3 years of clinical/ coding experience; experience in workers' compensation or medical bill review strongly preferred.
Familiarity with state-specific workers' compensation regulations and treatment guidelines strongly preferred.
Strong analytical, communication, and documentation skills.
Experience with bill review platforms (e.g., Strataware, Medata, Mitchell) is a plus.