[Hiring] Third Party Reviewer @Mass General Brigham

Role Description

Responsible for conducting thorough and accurate reviews of healthcare billing and claims documentation.

• Review medical claims and billing documentation to ensure accuracy, completeness, and compliance with regulatory requirements, coding guidelines, and payer policies.
• Verify the appropriateness of billed services, procedures, and diagnosis codes.
• Identify potential compliance issues, including incorrect coding, unbundling, upcoding, and other billing irregularities.
• Conduct audits to ensure adherence to industry regulations, such as HIPAA and CMS guidelines.
• Evaluate the accuracy and adequacy of clinical documentation, ensuring it supports the billed services and complies with medical necessity guidelines.
• Collaborate with healthcare providers to obtain additional information or clarification, if necessary.
• Analyze claim denials and rejections, identify root causes, and recommend corrective actions to prevent future denials.
• Work closely with billing and coding teams to resolve claim discrepancies and resubmit claims, if needed.
• Identify potential fraudulent activities or abuse in billing practices.
• Report suspicious activities and work with internal compliance teams and external agencies to investigate and resolve fraud cases.

Qualifications

• High School Diploma or Equivalent required.
• Experience in medical billing, claims processing, or coding within a healthcare environment, with a strong focus on third-party payer guidelines and regulations. 1-2 years preferred.
• In-depth knowledge of coding systems (e.g., ICD-10-CM, CPT, HCPCS) and billing requirements across various healthcare settings.
• Familiarity with billing and coding compliance regulations, such as HIPAA, CMS guidelines, and National Correct Coding Initiative (NCCI) edits.
• Strong analytical skills and attention to detail, with the ability to review and interpret complex billing and coding documentation.
• Proficiency in using billing software and electronic health record (EHR) systems.
• Excellent communication and interpersonal skills, with the ability to collaborate effectively with internal teams, healthcare providers, and insurance companies.

Requirements

• M-F Eastern Business hours required for remote role; shifts may range between 6AM-6PM EST.
• A quiet, secure, stable, HIPAA-compliant workstation is required.
• Remote work location: 399 Revolution Drive.
• Scheduled Weekly Hours: 40.
• Employee Type: Regular.
• Work Shift: Day (United States of America).
• Pay Range: $19.81 - $28.30/Hourly.
• Grade: 3.

Benefits

• Comprehensive benefits.
• Career advancement opportunities.
• Differentials, premiums, and bonuses as applicable.
• Recognition programs designed to celebrate your contributions and support your professional growth.