Appeals Nurse

Blue Cross Blue Shield of Massachusetts•Hingham, MA

1d•$42 - $51

About The Position

Ready to help us transform healthcare? Bring your true colors to blue. Job Profile: Appeals Nurse Reviewer Job Code: HCM101 Business Title: Appeals Nurse Reviewer Reports To: Patricia Corsini RN, BSN 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.

Requirements

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
Registered Nurse with current Massachusetts licensure required (BSN preferred)
Credentialed coder (CPC, CCS) required
Minimum 3-5 years acute care experience
High school degree or equivalent required unless otherwise noted above

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.