[Hiring] Claims Review Specialist @Mass General Brigham

Role Description

The D‑SNP Claims Review Specialist reviews and processes Senior Care Options (SCO) and One Care medical claims requiring manual intervention when auto‑adjudication is not achieved. The Specialist ensures claims are adjudicated accurately, timely, and in compliance with Mass General Brigham Health Plan administrative policies, operational procedures, and clinical guidelines. The ideal candidate brings hands‑on experience with SCO and One Care claims processing and demonstrated proficiency in QNXT or similar claims adjudication systems (e.g., Facets).

• Adjudicate claims to pay, deny, or pend as appropriate in a timely and accurate manner according to company policy and desktop procedure.
• Review and research assigned claims by navigating multiple systems and platforms, then accurately capturing the data/information necessary for processing (e.g., verify pricing/fee schedules, contracts, Letter of Agreement, prior authorization, applicable member benefits).
• Manually enters claims into claims processing system as needed.
• Ensure that the proper benefits are applied to each claim by using the appropriate processes and desktop procedures (e.g., claims processing policies, procedures, benefits plan documents).
• Communicate and collaborate with external department to resolve claims errors/issues, using clear and concise language to ensure understanding.
• Learn and leverage new systems and training resources to help apply claims processes/procedures appropriately (e.g., online training classes, coaches/mentors).
• Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction.
• Create/update work within the call tracking record-keeping system.
• Adhere to all reporting requirements.
• Keep up to date with Desktop Procedures and effectively apply this knowledge in the processing of claims and in providing customer service.
• Identify and escalate system issues, configuration issues, pricing issues etc., in a timely manner.
• Process member reimbursement requests as needed.

Qualifications

• High School Diploma or Equivalent required; Associate's degree preferred.
• Related Healthcare Experience 1-2 years required.
• At least 2-3 years of previous experience in the health insurance industry in functions such as claims processing highly preferred.
• SCO and OneCare claims processing experience highly preferred.
• Knowledge of healthcare claims processes for (D-SNP/fully-integrated Medicare & Medicaid/Mass Health highly preferred).
• Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes highly preferred.
• Knowledge of medical terminology highly preferred.
• Familiarity with insurance plans, government programs, and their billing requirement preferred.
• Knowledge of claim forms (professional and facility) highly preferred.
• Professional Coder Certificate is highly desirable.
• Strong customer service orientation and ability to handle sensitive or difficult situations with empathy and professionalism.

Requirements

• This is a remote role that can be done from most US states.
• This is a full-time schedule (8-4:30 pm or 8:30-5:00 pm ET).
• Remote workdays require a stable, secure, quiet, and compliant workspace.
• Scheduled Weekly Hours: 40.
• Employee Type: Regular.
• Work Shift: Day (United States of America).
• Pay Range: $17.71 - $25.28/Hourly.
• Grade: 2.

Benefits

• Competitive salaries.
• Comprehensive benefits package.
• Flexible work options.
• Career growth opportunities.
• Recognition programs designed to celebrate your contributions and support your professional growth.