The Role
The Claims Nurse Reviewer is responsible for reviewing claims, 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 claims for medical necessity, appropriate coding, and pricing of claims for payment.

The Team
As an integral part of the Complex Claims team, the Claims Nurse Reviewer will serve as a liaison and business expert for all matters concerning appropriate coding and Medical Policy interpretation. This role works collaboratively with Provider Service, Claims, Network Management, Physician Review, and Medical and Payment Policy teams.

Key Responsibilities:

• Review pending claims 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.
• Review Prolonged Illness Cases (PIC) to determine if diagnoses, treatment, and medication regime satisfy established BCBS parameters for Prolonged Illness benefits.
• Review Continuation of Care requests in accordance with Consolidated Appropriations Act (CAA)
• Conduct training and use existing documentation to develop and revise workflows.
• Act as claims representative in corporate meetings involving changes in medical policy, pricing files and table updates, and share information with the team.

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 claims.
• 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
• Strong working knowledge of Medical Policy, RTMS, NASCO, and MHK preferred

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

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.

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 are 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.

WHY Blue Cross Blue Shield of MA?

We understand that theandcan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourpage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "" Page.