Blue Cross Blue Shield of Massachusetts · 9 hours ago
Clinical Reviewer - FEP
Hingham, MA
Full-time
Onsite
Mid Level
$47.40/hr - $57.93/hr
3+ years expBlue Cross Blue Shield of Massachusetts is committed to transforming healthcare. The Post-Service Claims Nurse Reviewer plays a crucial role in ensuring the integrity of the claims process by leveraging clinical expertise to assess claims in accordance with FEP guidelines.
AssociationCommunitiesHealth InsuranceInsuranceMedicalNon Profit
Responsibilities
Conduct comprehensive post service provider appeal reviews, applying contractual provisions, FEP Medical Policy and Utilization Guidelines, and BCBSMA guidelines to facilitate decisions on claims payment related to medical necessity
Perform in-depth clinical assessments to interpret complex medical information, clearly documenting relevant conditions and circumstances to support accurate claim adjudication
Utilize comprehensive knowledge of HCPCS/ CPT, ICD10-CM, HIPAA, subscriber certificate language, pricing, and medical policy to determine appropriateness of claims payment or denial in collaboration with the Physician Review Unit
Responsible for appropriate payment decisions and pricing of services submitted with unlisted HCPCS/CPT codes in accordance with individual provider contractual agreements and usual and customary payment
Act as the definitive subject matter expert and liaison for all matters concerning appropriate coding, medical policy interpretation, and clinical guidelines for our internal business partners
Identify or validate, via the FEP HUB process, the integrity of procedure and diagnosis files for situations in which policy edits can contribute to cost-effective medical review claim processing and opportunities to decrease administrative costs
Act as clinical liaison to the FEP Reconsideration and Appeals specialist to ensure full and fair review with documentation of response to member reconsiderations, appeals and inquiries using all pertinent clinical information and review resources
Identify and report possible fraud and abuse, potential quality of care issues, service or treatment delays. Provide referrals to appropriate Business Partners as necessary
Partner with Health Management UM team for consistency in pre-service/post service clinical review process and training activities
Other responsibilities as assigned by Leader
Qualification
Required
Active licensure in Massachusetts required
Current certification in coding required
In-depth knowledge of HCPCS, CPT, ICD10-CM diagnosis and procedure codes and Plan benefit design for FEP
Strong working knowledge of Medical Policy, FDA, Payment Policy, NASCO claims systems, MHK, CMS guidelines and impacts of FEP Direct system claim edits
Possesses superior analytical and research skills, with a proven ability to critically evaluate complex medical records to determine appropriateness of care and ensure payment integrity
A high degree of initiative and self-motivation, with the ability to work autonomously and thrive in a high-volume, dynamic environment to consistently meet and exceed business objectives
Demonstrates strong technical proficiency across multiple IT systems, with the capacity to quickly adapt to and master new software and platforms
A versatile professional who excels both independently and as part of a collaborative team, consistently contributing to performance excellence and a high standard of customer service
3-5 years of clinical experience
High school degree or equivalent required unless otherwise noted above
Preferred
A Bachelor of Science in Nursing (BSN) degree preferred
Utilization management experience. FEP experience preferred
Experience in an operational environment preferred
Benefits
Paid time off
Medical/dental/vision insurance
401(k)
A suite of well-being benefits
Company
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of Massachusetts is a state licensed private health insurance company
1001-5000 employees
H1B Sponsorship
Blue Cross Blue Shield of Massachusetts has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (11)
2024 (21)
2023 (8)
2021 (2)
2020 (6)
Funding
Current Stage
Late StageLeadership Team
Sarah Iselin
President and Chief Executive Officer
Sophie Clarke
Chief Strategy Officer
Recent News
2025-12-09
2025-11-24
Boston Globe
2025-11-14
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