Appeals Nurse, Certified Coder

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  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

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  Use comprehensive knowledge of coding guidelines to approve or reject payment for services provided according to nationally recognized billing processes.

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  Uses comprehensive Nationally known criteria, Medical Policy and Benefits to review appeals.

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  Collaborate with the Physician Review Unit to assist with medical necessity determinations and billing practices.

• 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             

We understand that the confidence gap and imposter syndrome can  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 our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to 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.