Clinical Appeals Nurse Reviewer

Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 80 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 3 million members, and consistently offering security, stability, and peace of mind to both our members and associates. As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity.

The Clinical Appeals Nurse Reviewer is responsible for applying sound clinical judgement to review provider and member appeals for denied services according to appropriate guidelines. This position requires strong clinical judgment, ability to analyze medical records and apply medical knowledge to make the most appropriate decision within regulatory timeframes. The Team: As an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will serve as a liaison and business expert for member and provider submitted appeals. Working collaboratively with Physician review unit, Utilization Management, Case Management, Member appeals and Grievance, Provider Service, Claims, Network Management, and Medical Policy teams. This role is eligible for our eWorker persona (remote).

Review provider and member appeals utilizing sound clinical judgement, medical policy, clinical guidelines, and benefits to appropriately decision the medical necessity of services requested. Research and respond to all medical, dental, and behavioral health appeal requests according to regulatory and accreditation standards and timeframes. Collaborate with the Physician Review Units to assist with medical necessity determinations.