[Hiring] Medical Case Reviewer II @Capitol Bridge, LLC.

Role Description

Capitol Bridge is seeking an experienced Medical Case Reviewer II to evaluate Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) proposals. In this role, you will:

• Analyze complex medical records.
• Project future medical and prescription drug costs related to workers' compensation injuries.
• Recommend WCMSA allocations in accordance with CMS guidelines.

Qualifications

• Bachelor’s Degree in Nursing (BSN/RN) or clinical healthcare field, OR a Juris Doctorate (JD) from an accredited institution.
• Minimum of 1+ years of direct experience performing Medicare Set-Aside (MSA) allocations or complex medical record reviews for workers' compensation claims.
• Active, hands-on experience with:
  • ICD-10, CPT, and HCPCS coding systems.
  • Medical cost pricing utilizing usual & customary rates and state-specific Workers' Compensation fee schedules.
  • CMS policy, coverage guidelines, and WCMSA threshold requirements.
• Preferred Certifications:
  • Medicare Set-Aside Certified Consultant (MSCC)
  • Certified Medicare Secondary Payer (CMSP)

Requirements

• Audit complex medical records and WCMSA proposals to ensure full compliance with CMS threshold requirements and Medicare Secondary Payer regulations.
• Independently calculate and price future Medicare-covered medical treatment, therapies, surgical interventions, and prescription drug expenses related to workplace injuries.
• Render formal allocation determinations based on clinical judgment, legal parameters, state fee schedules, and CMS guidelines.
• Identify missing documentation or clinical records and issue formal development requests prior to final decision-making.

Benefits

• Base Salary: Starting at $70,000/year (commensurate with experience)
• Comprehensive Medical, Dental, and Vision plans
• 401(k) with company match
• Unlimited Vacation Policy + Paid Holidays