Pegasus Knowledge Solutions, Inc. · 3 weeks ago
Manager Clinical Bill Review
United States
Full-time
Remote
Senior Level, Lead/Staff, Director/Executive
7+ years expPegasus Knowledge Solutions, Inc. is seeking a Senior Manager Clinical Bill Review to lead a high-performing team of clinical bill review nurses. The role involves ensuring clinical oversight, operational discipline, and continuous improvement in the bill review lifecycle, focusing on Workers’ Compensation and Business Auto claims.
Information Technology
Hiring Manager
Vivek Mishra
Responsibilities
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
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
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
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
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
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
Qualification
Required
RN, BSN or higher required
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
Preferred
Advanced clinical credentials (e.g., MSN, NP) preferred
Prior experience in clinical decision support, medical policy development, or system/workflow design is a plus
Company
Pegasus Knowledge Solutions, Inc.
Founded in 1997, PKSI [Pegasus Knowledge Solutions, Inc.] is an independent, advanced analytics software and services organization, that partners with the industry leading providers to help customers create value from their data, bringing a range of talents, including data integration and preparation, big data environments, data mining, predictive analytics, machine learning and text mining, as well as dashboarding and visualization.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
Lawrence Hall
Director of AI Solutions and Partnerships
Company data provided by crunchbase