Sr Manager- Clinical Bill Review

Position Overview

The Clinical Bill Review Senior Manager is responsible for leading a high-performing team of onshore and offshore clinical bill review nurses supporting Workers Compensation and Business Auto claims. This position ensures clinical oversight, operational discipline, and continuous improvement across the bill review lifecycle. The ideal candidate brings deep clinical knowledge, strong command of medical coding and documentation, and expertise in the nuances of WC and Business Auto billing to ensure appropriate payment decisions are rendered based on regulatory guidelines and clinical justification.

Key Responsibilities

1. Clinical Leadership & Oversight

• Provide day-to-day clinical guidance and oversight for the nursing team reviewing medical bills under WC and Business Auto policies.
• Ensure clinical appropriateness of reviewed services, validating necessity and medical justification based on documentation and coding.
• Interpret and apply jurisdictional variations in Workers' Comp regulations and Business Auto medical review guidelines.

2. Team Management & Performance Optimization

• Lead a globally distributed team of nurses (onshore and offshore), driving consistency in performance and adherence to clinical review protocols.
• Monitor productivity daily, review trends, and proactively address issues to maintain throughput in line with operational targets.
• Partner with HR and training functions to onboard, coach, and continuously develop nurse reviewers.

3. Quality Assurance & Error Prevention

• Design and manage a QA framework that flags clinical or coding errors and ensures corrective actions are implemented.
• Use QA findings to refine reviewer education, update clinical policies, and close knowledge gaps.
• Ensure alignment of QA findings with operational workflows and business rules for bill review.

4. Workflow Engineering & Technology Integration

• Partner with Product and Engineering teams to enhance workflow platforms, automation tools, and reviewer interfaces.
• Recommend and prioritize workflow optimizations and technical enhancements based on reviewer experience and operational outcomes.
• Identify opportunities to streamline the clinical review process using decision support tools and automation where appropriate.

5. Data & Reporting Collaboration

• Work with analytics teams to create dashboards and reports that track team performance, billing trends, and review outcomes.
• Leverage reporting insights to guide business decisions, justify staffing needs, and identify emerging patterns in provider behavior or claim complexity.
• Translate operational data into actionable recommendations for upper-level leadership.

6. Knowledge Management & Medical Bill Logic Development

• Lead the development of a dynamic, rules-based Knowledge Management system that governs clinical bill review selection.
• Define and continuously update logic rules for which bills require clinical review based on service codes, provider type, documentation availability, jurisdiction, and risk indicators.
• Ensure the database reflects regulatory requirements and clinical best practices for WC and Business Auto medical management.

Qualifications

• RN, BSN or higher required. Advanced clinical credentials (e.g., MSN, NP) preferred.
• Minimum 7 10 years of clinical experience with at least 3 5 years in a leadership role within bill review, utilization review, or claims operations.
• Deep understanding of Workers' Compensation and Business Auto regulatory environments, clinical treatment guidelines, and medical bill coding (CPT, ICD-10, HCPCS).
• Proven experience managing offshore clinical teams and navigating the complexities of global operations.
• Strong data orientation with demonstrated experience interpreting production reports and driving decisions based on analytics.
• Prior experience in clinical decision support, medical policy development, or system/workflow design is a plus.

Key Competencies

• Deep clinical acumen and regulatory awareness in WC/Business Auto
• High operational rigor with ability to lead and scale global teams
• Strategic mindset with ability to bridge clinical, technical, and business domains
• Strong communication and cross-functional collaboration skills
• Quality- and process-improvement focus
• Skilled at balancing speed, compliance, and medical accuracy in review operations