Supervisor - Clinical Review

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The Role
The Senior Clinical Appeals Nurse Reviewer Supervisor facilitates, coordinates, and responds to provider appeals for denied services utilizing extensive clinical, regulatory, business, and coding knowledge. The Senior Clinical Appeals Nurse Reviewer Supervisor works closely with Clinical Appeals Nurse reviewers and coders as a liaison for questions and support in decision making.  Collaborates with the Physician Review Units, Medical & Payment Policy Departments, Provider Service, Member Service and Claims Area to research and resolve provider claims appeals, Authorization appeals and member appeals.

The Team
As an integral part of the Clinical Appeals team, the Senior Appeals Nurse Reviewer Supervisor will serve as a liaison and business expert for appeals. This role works collaboratively with Provider Service, Claims, Member Services, 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 and authorization 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 coding and clinical decision criteria, Medical Policy and Benefits to review authorization appeals.
• Collaborate with the Physician Review Unit to assist with medical necessity determinations and billing practices.
• Cross trained on all aspects of clinical appeals and provides support and assistance as needed.

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.
• The ability to motivate and lead cross-functional teams of clinical and non-clinical staff.
• 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 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 1 year experience leading teams (nursing or coding leadership preferred)
• Minimum 3-5 years acute care experience (inpatient med/surg, surgical or procedural area preferred)

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Hingham

Time Type

Full time

Salary Range: $93,150.00 - $113,850.00

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 the confidence gap and