Case Reviewer II/Clinical Reviewer (59807)

About Capitol Bridge

Founded in 2012, Capitol Bridge is based in Arlington, Virginia with proven expertise providing independent medical reviews, records/data management services, medical coding, administrative staffing, and eligibility reviews.

Capitol Bridge LLC is currently seeking a dynamic and experienced individual to join our team as a Medical Case Reviewer II.

This is a full-time remote role open to candidates throughout the United States.

Hours for this position are Monday-Friday 8:00am - 5:00pm.

Program Overview:

The Workers' Compensation Review Contractor (WCRC) shall, in accordance with CMS guidelines, evaluate Workers' Compensation Medicare Set-aside Arrangement (WCMSA) proposals and project the future medical costs, including prescription drugs, related to the workers' compensation (WC) injury, illness, or disease that would be otherwise reimbursable by Medicare. This future cost projection is known as the WCMSA. The contractor shall, upon reviewing complete WCMSA proposals, recommend the WCMSA amount for each proposal to CMS for final determination.

The purpose of this contract is to procure an impartial entity, not as an agent of the Federal government, to independently price the future Medicare-covered medical services costs related to the WC injury, illness, and/or disease and to price the future Medicare covered prescription drug expenses related to the WC injury, illness and/or disease thereby taking Medicare's payment interests appropriately into account.

Pay and Benefits:

Base Rate:starting at $70,000

Medical, Dental, and Vision benefits available

401(k) available with company match

Paid holidays

Unlimited Vacation Time

Essential Job Duties:

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  Review and evaluate Workers' Compensation Medicare Set-Aside (WCMSA) proposals, including medical records, to determine if the proposal meets CMS threshold requirements and adequately considers Medicare's interests as pertaining to future medical needs of beneficiaries.

  
  

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  Ensure all basic documentation requirements are available or requested via development action prior to making a determination.

  
  

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  Render determinations based on professional experience.

  
  

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  Implement CMS policy.

  
  

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  Other duties as assigned by management.

  
  

Education and Experience Requirements:

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  Bachelor's degree from an accredited college or university in clinical healthcare (nursing, medical) and/or Juris Doctorate from an accredited law school. Equivalent or higher education level/experience required.

  
  

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  At least one year of Medicare Set-Aside (MSA) related experience and/or medical record review experience, required.

  
  

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  Possess medical knowledge and experience with medical terminology, ICD-10 Codes, and Current Procedure Terminology Codes (CPT) codes.

  
  

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  Experience with pricing medical items and services using usual and customary and workers' compensation fee schedules.

  
  

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  Medicare Set-Aside Certified Consultant (MSCC) certification and/or Certified Medicare Secondary Payer (CMSP) certification preferred.

  
  

Preferred additional knowledge of:

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  Healthcare Common Procedure Coding System (HCPCS) coding practices.

  
  

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  Medicare coverage guidelines.

  
  

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  Pharmacology.

  
  

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  State-specific workers' compensation guidelines and pricing structures.

  
  

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  Health Insurance Portability and Accountability Act (HIPAA) and related healthcare confidentiality regulations.

  
  

Reasonable Accommodation

Capitol Bridge complies with federal and state disability laws and makes reasonable accommodation for applicants and employees with disabilities. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, or to receive other benefits and privileges of employment, please contact your recruiter.

EEO Statement

Capitol Bridge is an Equal Opportunity Employer. All employment decisions at Capitol Bridge are based on business needs, job requirements and individual qualifications, without regard to race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate.

Texting Notice

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