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, CPT, ICD-10, reject messaging, Modifiers 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

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location
HinghamTime Type
Full time

Hourly Range: $41.72 - $50.99

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.