Clinical Reviewer - FEP

Overview

Position:
Post-Service Claims Nurse Reviewer. The role safeguards the integrity of the claims process in a post-service, pre-payment environment. It leverages clinical expertise and business acumen to ensure all claims are processed in accordance with Federal Employee Program (FEP) guidelines and National Committee for Quality Assurance (NCQA) standards. The Nurse Reviewer facilitates medical necessity and coding integrity determinations for complex services, including medical technologies, medical benefit drug reviews, and high-dollar or high-utilization claims.

Reviews must align with the FEP Hierarchy, BCBSMA contractual agreements, and corporate payment policies. The position supports member disputed claims processes and urgent care appeals. This role requires a credentialed clinical coder with a current, active certification from a recognized organization (e.g., AAPC or AHIMA) and a commitment to ongoing credential maintenance. The role involves collaboration across departments with the FEP Business Unit, the Health and Medical Management division, and the Physician Review Units to ensure accuracy and consistency.

This position is eligible for the following persona(s): eWorker, mobile, resident.

• 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, ICD-10-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 internal business partners
• Identify or validate, via the FEP HUB process, the integrity of procedure and diagnosis files when policy edits contribute to cost-effective medical review 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

• In-depth knowledge of HCPCS, CPT, ICD-10-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
• Superior analytical and research skills, with the ability to critically evaluate complex medical records to determine appropriateness of care and ensure payment integrity
• High initiative and self-motivation, with the ability to work autonomously in a high-volume, dynamic environment to meet and exceed objectives
• Strong technical proficiency across multiple IT systems and the ability to quickly adapt to new software and platforms
• Versatile professional who excels both independently and as part of a collaborative team, contributing to performance excellence and high standards of customer service

• Active licensure in Massachusetts required
• BSN degree preferred
• 3-5 years of clinical experience
• Current certification in coding required
• Utilization management experience; FEP experience preferred
• Experi…