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Blue Cross Blue Shield of Massachusetts Appeals Nurse Medical Coding Reviewer in Hingham, Massachusetts

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Respond to providers' appeals for individual consideration for medical and payment policy denials of services performed. Review cases by utilizing extensive medical, coding and business knowledge. Serve as a liaison and business expert for all matters concerning appropriate coding and Medical Policy interpretation. Prioritize caseload to maintain divisional goals for inventory levels, aging, and provider satisfaction

The RoleThe Appeals Nurse Reviewer is responsible for reviewing provider claims appeals, validating coding and medical necessity of the services submitted and pricing the claims according to appropriate guidelines. This position requires strong clinical and medical coding skills to review provider claim appeals for medical necessity, appropriate coding, and pricing of claims for payment. The TeamAs an integral part of the Clinical Appeals team, the Appeals Nurse Reviewer will serve as a liaison and business expert for specific provider submitted claim appeals. This role works collaboratively with Provider Service, Claims, Network Management, Physician Review, and Medical and Payment Policy teams.Key Responsibilities:

  • Review provider claim 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.

  • Use comprehensive knowledge of coding guidelines to approve or reject payment for services provided according to nationally recognized billing processes.

  • 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.

  • Excellent organizational and prioritization skills with the ability to problem solve independently and in collaboration with teammates, physicians and other associates to appropriately adjudicate claim appeals.

  • In-depth knowledge of HCPCS, CPT, ICD-10 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

LocationHingham, QuincyTime TypeFull time

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. We provide a flexible hybrid work model in which roles are designated as resident (on site 4-5 days/week), mobile (on site 1-3 days/week), or eworker (on site 0-3 days/month).

Blue Cross Blue Shield of Massachusetts, has a COVID-19 vaccination requirement for building entry. Your offer of employment is dependent upon either being fully vaccinated for COVID-19 or an accommodation based on a disability or sincerely held religious belief, practice, or observance by submitting a request to Human Resources.

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power , Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.