Case Reviewer II/Clinical Reviewer (60740)

Job Title: Medical Case Reviewer II - Workers' Compensation Medicare Set-Aside (WCMSA)

Location: Remote (US-Based)

Schedule: Monday - Friday, 8:00 AM - 5:00 PM EST

About Capitol Bridge

Founded in 2012, Capitol Bridge is based in Arlington, Virginia, providing specialized independent medical reviews, data management, medical coding, administrative staffing, and eligibility reviews.

Position Overview

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, and recommend WCMSA allocations in accordance with CMS guidelines.

To be considered for this role, candidates must meet the following criteria:

Education: Bachelor's Degree in Nursing (BSN/RN) or clinical healthcare field, OR a Juris Doctorate (JD) from an accredited institution.

Required Experience: Minimum of 1+ years of direct experience performing Medicare Set-Aside (MSA) allocations or complex medical record reviews for workers' compensation claims.

Technical Proficiency: 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)

WCMSA Proposal Evaluation: Audit complex medical records and WCMSA proposals to ensure full compliance with CMS threshold requirements and Medicare Secondary Payer regulations.

Future Cost Projections: Independently calculate and price future Medicare-covered medical treatment, therapies, surgical interventions, and prescription drug expenses related to workplace injuries.

Evidence-Based Determinations: Render formal allocation determinations based on clinical judgment, legal parameters, state fee schedules, and CMS guidelines.

Case Development: Identify missing documentation or clinical records and issue formal development requests prior to final decision-making.

Base Salary: Starting at $70,000/year (commensurate with experience)

Health & Wellness: Comprehensive Medical, Dental, and Vision plans

Financial: 401(k) with company match

Time Off: Unlimited Vacation Policy + Paid Holidays

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.

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