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Position Summary: The Post-Service Claims Nurse Reviewer is a pivotal role responsible for safeguarding the integrity of our claims process in a post-service, pre-payment environment. In this position, you will leverage your deep clinical expertise and business acumen to ensure all claims are processed in strict accordance with Federal Employee Program (FEP) guidelines and National Committee for Quality Assurance (NCQA) standards. The Nurse Reviewer facilitates both medical necessity and coding integrity determinations for a variety of complex services, including individual consideration of medical technologies, medical benefit drug reviews, and high-dollar or high-utilization claims. All reviews must adhere to the FEP Hierarchy, be consistent with BCBSMA contractual agreements, and align with corporate payment policies. Utilizing evidence-based guidelines and extensive knowledge of medical coding, you will also play a key role in supporting the member disputed claims process and resolving urgent care appeals. This position requires a credentialed clinical coder. Candidates must hold a current, active certification from a recognized organization (such as AAPC or AHIMA) and demonstrate a commitment to upholding this credential through continuous education. This position requires close collaboration across departments, working collaboratively with the FEP Business Unit, the broader Health and Medical Management division, and our Physician Review Units to ensure accuracy and consistency. This position is eligible for the following persona(s): eWorker, mobile, resident.
Responsibilities
Conduct comprehensive post service provider appeal reviews, applying contractual provisions, FEP Medical Policy and Utilization Guidelines, and BCBSMA guidelines to facilitate decisions on claims payment related to medical necessity
Perform in-depth clinical assessments to interpret complex medical information, clearly documenting relevant conditions and circumstances to support accurate claim adjudication
Utilize comprehensive knowledge of HCPCS/ CPT, ICD10-CM, HIPAA, subscriber certificate language, pricing, and medical policy to determine appropriateness of claims payment or denial in collaboration with the Physician Review Unit
Responsible for appropriate payment decisions and pricing of services submitted with unlisted HCPCS/CPT codes in accordance with individual provider contractual agreements and usual and customary payment
Act as the definitive subject matter expert and liaison for all matters concerning appropriate coding, medical policy interpretation, and clinical guidelines for our internal business partners
Identify or validate, via the FEP HUB process, the integrity of procedure and diagnosis files for situations in which policy edits can contribute to cost-effective medical review claim processing and opportunities to decrease administrative costs
Act as clinical liaison to the FEP Reconsideration and Appeals specialist to ensure full and fair review with documentation of response to member reconsiderations, appeals and inquiries using all pertinent clinical information and review resources
Identify and report possible fraud and abuse, potential quality of care issues, service or treatment delays.
Provide referrals to appropriate Business Partners as necessary
Partner with Health Management UM team for consistency in pre-service/post service clinical review process and training activities
Other responsibilities as assigned by Leader
Requirements
In-depth knowledge of HCPCS, CPT, ICD10-CM diagnosis and procedure codes and Plan benefit design for FEP
Strong working knowledge of Medical Policy, FDA, Payment Policy, NASCO claims systems, MHK, CMS guidelines and impacts of FEP Direct system claim edits
Possesses superior analytical and research skills, with a proven ability to critically evaluate complex medical records to determine appropriateness of care and ensure payment integrity
A high degree of initiative and self-motivation, with the ability to work autonomously and thrive in a high-volume, dynamic environment to consistently meet and exceed business objectives
Demonstrates strong technical proficiency across multiple IT systems, with the capacity to quickly adapt to and master new software and platforms
A versatile professional who excels both independently and as part of a collaborative team, consistently contributing to performance excellence and a high standard of customer service
Active licensure in Massachusetts required
Current certification in coding required
Utilization management experience
Nice-to-haves
A Bachelor of Science in Nursing (BSN) degree preferred
FEP experience preferred.
Experience in an operational environment preferred.
Benefits
We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
