Clinical Reviewer - FEP

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.

Major Responsibilities: As a Post-Service Claims Nurse Reviewer, you will be entrusted with critical responsibilities that directly influence member outcomes and financial integrity. Your primary duties will include:

• 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

Qualifications:

• 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

Experience and Education:

• Active licensure in Massachusetts required
• A Bachelor of Science in Nursing (BSN) degree preferred
• 3-5 years of clinical experience
• Current certification in coding required
• Utilization management experience. FEP experience preferred.
• Experience in an operational environment preferred

#LI-HYBRID

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 theconfidence gapandimposter syndromecan 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 ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto 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 "How We Work" Page.