Blue Cross Blue Shield Of Massachusetts
AppealsNurse(CertifiedCoder)
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“Appeals Nurse (Certified Coder) at Blue Cross Blue Shield Of Massachusetts. Skills: clinical judgement, coding knowledge, claims appeals, nursing judgement, HCPCS, CPT, ICD-10. facilitates, coordinates, and responds to provider appeals for denied services. Collaborates with the Physician Review Units, Medical & Payment Policy Departments, Provider Service, Member Service and Claims Area to research and resolve provider claims appeals”
What You'll Achieve.
appropriately adjudicate provider and facility claims appeals; approve or reject payment for services provided
Industry & Context.
problem solve independently; problem solve in collaboration with teammates, physicians and other associates
Current Massachusetts licensure
What They're Looking For.
Must Have
Registered Nurse with certified coding experience, ability to apply nursing judgement to determine the medical necessity of services provided, ability to accurately analyze claims submitted for appropriate billing and price claims for payment accurately, ability to accurately analyze clinical documentation for appropriate decision making, Excellent organizational and prioritization skills, 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, Registered Nurse with current Massachusetts licensure, Credentialed coder (CPC, CCS)
Nice to Have
BSN preferred
What You'll Do.
and responds to provider appeals for denied services
Collaborates with the Physician Review Units
Medical & Payment Policy Departments
Member Service and Claims Area to research and resolve provider claims appeals
Review appeals utilizing sound clinical judgement
payment policy guidelines
contractual obligations
and billing practices
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
How You'll Work.
Team & Collaboration
Collaborates with the Physician Review Units, Medical & Payment Policy Departments, Provider Service, Member Service and Claims Area to research and resolve provider claims appeals; works collaboratively with Provider Service, Claims, Network Management, Physician Review, and Medical and Payment Policy teams; collaboration with teammates, physicians and other associates
Full Job Description
## **Ready to help us transform healthcare? Bring your true colors to blue. ** **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. **Key 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. **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. * 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,
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