[Hiring] Claims Review Specialist @Mass General Brigham

Role Description

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.

We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

Responsible for evaluating claims submitted by healthcare providers, insurance companies, and patients to ensure proper coding, documentation, and adherence to billing regulations.

Essential Functions

• Review and assess medical claims submitted by healthcare providers, insurance companies, and patients to identify any discrepancies, errors, or potential fraud.
• Analyze and validate the assigned diagnosis codes (ICD-10) and procedure codes (CPT) on medical claims to ensure accurate representation of the provided healthcare services.
• Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records.
• Analyze claim payment amounts and compare them to contracted rates, fee schedules, and industry benchmarks.
• Identify underpayments, overpayments, and potential billing errors.
• Conduct comprehensive audits of medical claims to verify compliance with billing regulations, payer policies, and internal policies and procedures.
• Stay updated on insurance company policies, billing guidelines, and reimbursement rules.

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.
• Knowledge of medical billing and coding principles, reimbursement methodologies, and insurance claim submission processes.
• Knowledge of healthcare regulations and compliance, including HIPAA guidelines.
• Familiarity with insurance plans, government programs, and their billing requirements.
• Strong attention to detail and accuracy in claim submissions and recordkeeping.
• Excellent communication skills, both written and verbal, to interact effectively with insurance companies, patients, and colleagues.
• Strong customer service orientation and ability to handle sensitive or difficult situations with empathy and professionalism.

Requirements

• This is a full-time role with a Monday through Friday schedule, generally 8:30-5:00 PM Eastern Time.
• This position is eligible for remote work from approved U.S. locations, subject to organizational requirements.
• Remote employees must maintain a stable internet connection and a secure, private, quiet workspace appropriate for handling confidential and protected health information.
• Remote workspace requirements, including privacy and security standards, may be verified in accordance with organizational policy.

Benefits

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