Clinical Reviewer - FEP

Blue Cross Blue Shield of Massachusetts(1 month ago)

HybridFull TimeMedior$94,800 - $115,860Health and Medical Management

About this role

The Post-Service Claims Nurse Reviewer safeguards the integrity of post-service, pre-payment claims processing by applying clinical expertise to ensure compliance with FEP and NCQA standards. The role evaluates medical necessity and coding integrity for complex and high-dollar claims, supports disputed claims and appeals, and works closely with internal business units and physician review teams. A credentialed clinical coder is required, and the position emphasizes evidence-based decision making and adherence to contractual and corporate payment policies.

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Required Skills

Clinical Review
Medical Coding
HCPCS
CPT
ICD10-CM
Medical Policy
Utilization Management
Claims Adjudication
Clinical Assessment
Analytical Skills

+2 more

Qualifications

Active Massachusetts License
BSN Preferred
Coding Certification (AAPC/AHIMA)
High School Diploma

About Blue Cross Blue Shield of Massachusetts

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