Appeals Nurse

Ready to help us transform healthcare? Bring your true colors to blue. The Role The Clinical Appeals Nurse Reviewer facilitates, coordinates, and responds to provider appeals for denied services utilizing extensive clinical, regulatory, business, and coding knowledge. Collaborates with the Physician Review Units, Medical & Payment Policy Departments, Provider Service, Member Service and Claims Area to research and resolve provider claims appeals. The Team As an integral part of the Clinical Appeals team, the Appeals Nurse Reviewer will serve as a liaison and business expert for claims appeals. This role works collaboratively with Provider Service, Claims, Network Management, Physician Review, and Medical and Payment Policy teams. Key Responsibilities Review appeals utilizing sound clinical judgement, medical policy, payment policy guidelines, pricing files, contractual obligations, and billing practices, all to appropriately adjudicate provider and facility claims appeals. Use comprehensive knowledge of coding guidelines to approve or reject payment for services provided according to nationally recognized billing processes. Uses comprehensive Nationally known criteria, Medical Policy and Benefits to review appeals. Collaborate with the Physician Review Unit to assist with medical necessity determinations and billing practices. Key Qualifications Registered Nurse with certified coding experience and the ability to apply nursing judgement to determine the medical necessity of services provided. The ability to accurately analyze claims submitted for appropriate billing and price claims for payment accurately. The ability to accurately analyze clinical documentation for appropriate decision making. Excellent organizational and prioritization skills with the ability to problem solve independently and in collaboration with teammates, physicians and other associates to appropriately adjudicate appeals. In-depth knowledge of HCPCS, CPT, ICD-10, reject messaging, Modifiers and not otherwise classified (NOC) coding, all to validate billing and services. Education and Experience Registered Nurse with current Massachusetts licensure required (BSN preferred). Credentialed coder (CPC, CCS) required. Minimum 3-5 years acute care experience. Minimum Education Requirements High school degree or equivalent required unless otherwise noted above. Location: Hingham Time Type: Full time Hourly Range: $41.72 - $50.99 We offer a comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well‑being benefits to eligible employees. Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that is allocable to a particular employee remains in the Company’s sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. #J-18808-Ljbffr Blue Cross Blue Shield of Massachusetts