Clinical Bill Review Nurse

1 week ago

Mandaluyong, Philippines Genfinity Full time

Genfinity Mandaluyong, National Capital Region, Philippines Clinical Bill Review Nurse As a Clinical Bill Review Nurse, you will review medical bills and associated documentation to ensure accuracy, medical necessity, and compliance with workers’ compensation guidelines. You will support payment integrity by identifying inappropriate charges, ensuring adherence to jurisdictional fee schedules, and applying clinical expertise to support fair and accurate reimbursement. 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 PH 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 All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, ethnicity, age, disability, marital status, or any other characteristic protected by law. #J-18808-Ljbffr

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