Appeals Nurse

Role

The Clinical Appeals Nurse Reviewer facilitates, coordinates, and responds to provider appeals for denied services utilizing extensive clinical, regulatory, business, and coding knowledge. This role works collaboratively with Provider Service, Claims, Network Management, Physician Review, and Medical and Payment Policy teams to research and resolve provider claims appeals.

• Review appeals utilizing sound clinical judgement, medical policy, payment policy guidelines, pricing files, contractual obligations, and billing practices to appropriately adjudicate provider and facility claims.
• Apply coding guidelines to approve or reject payment for services according to nationally recognized billing processes.
• Collaborate with the Physician Review Unit to assist with medical necessity determinations and billing practices.

• Registered Nurse with certified coding experience; able to apply nursing judgement to determine the medical necessity of services.
• Accurate analysis of claims, billing, and clinical documentation for appropriate decision making.
• Excellent organizational and prioritization skills, with the ability to problem‑solve independently and collaboratively.
• In‑depth knowledge of HCPCS, CPT, ICD‑10, reject messaging, modifiers, and NOC coding.

Registered Nurse with current Massachusetts licensure (BSN preferred). Credentialed coder (CPC, CCS) required. Minimum 3‑5 years acute care experience.

Hingham, MA

Full time

$41.72 - $50.99

Variable pay is possible. Benefits include paid time off, medical/dental/vision insurance, 401(k), and a suite of well‑being benefits for eligible employees.

Blue Cross Blue Shield of Massachusetts is an Equal Employment Employer – veterans/disability. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law. Blue Cross Blue Shield of Massachusetts will not disclose compensation unless required by law or company policy.