Clinical Nurse Review

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