Clinical Nurse Review

MedRisk LLC; United States; On-site; USD 48,000 - 62,000; Full time

Job summary

MedRisk LLC is seeking a Clinical Nurse Review to perform nurse case management in a full-time professional role in the United States. The incumbent will review medical bills for medical necessity, ensure compliance with workers’ compensation guidelines, and collaborate with analysts, adjusters, and providers.

The job requires an active RN license, at least three years of clinical experience (workers’ compensation or bill review preferred), and strong analytical and documentation skills.

Qualifications

• Active, unrestricted RN license required.
• Minimum of 3 years clinical experience; experience in workers’ compensation or medical bill review strongly preferred.
• Familiarity with state‑specific workers’ compensation regulations and treatment guidelines
• Strong analytical, communication, and documentation skills
• 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.

Skills

Analytical skills

Communication skills

Documentation skills

Education

RN license (Active, unrestricted)

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Clinical Nurse Review

Nurse Case Management Regular Full-Time Professional US

7 days ago Requisition ID: 2943

Salary Range: $35.00 To $45.00 Hourly

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.

Primary Duties and 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.

Qualifications:

Active, unrestricted RN license (required)

Minimum of 3 years of clinical experience; experience in workers’ compensation or medical bill review strongly preferred

Familiarity with state-specific workers’ compensation regulations and treatment guidelines

Strong analytical, communication, and documentation skills

Experience with bill review platforms (e.g., Strataware, Medata, Mitchell) is a plus