Clinical Reviewer - Hingham
3 weeks ago
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 ICD10CM HIPAA subscriber certificate language pricing and medical policy to determine appropriateness of claims payment or denial in collaboration with the Physician Review Unit 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 diagnosis files for situations in which policy edits can contribute to cost-effective medical review claim processing opportunities decrease administrative costs Act as clinical liaison to the FEP Reconsideration Appeals specialist ensuring full fair review documentation response member reconsiderations appeals inquiries using pertinent clinical information review resources Identify report possible fraud abuse potential quality care issues service treatment delays Partner Health Management UM team consistency pre-servicepost servicclinical review process training activities Other responsibilities assigned Leader
Job description
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