[Hiring] DSNP Claims Resolution Coordinator @Mass General Brigham

Role Description

The DSNP Claims Resolution Coordinator is responsible for reviewing, researching, and resolving Dual Eligible Special Needs Plan (DSNP) claim inquiries, provider correspondence, and escalations received through Customer Service and internal business partners. This role determines whether claim adjustments are needed, applies Medicare and Medicaid benefit and payment guidelines, and ensures claims are processed accurately, timely, and in accordance with Mass General Brigham Health Plan policies, contractual requirements, and regulatory expectations. The coordinator uses independent judgment, strong analytical skills, and cross-functional collaboration to identify claim issues, support resolution, and help improve the member and provider experience.

• Review, research, and resolve assigned DSNP claim inquiries, provider correspondence, and escalations using QNXT and other internal systems.
• Determine appropriate claim action, including payment, denial, adjustment, manual entry, or pending for additional review, in accordance with applicable Medicare and Medicaid guidelines.
• Validate benefits, authorizations, pricing, fee schedules, contracts, Letters of Agreement, and member eligibility to support accurate and timely claim resolution.
• Maintain accurate documentation in applicable tracking systems, including call tracking records, claim notes, reports, and reimbursement request records.
• Communicate and collaborate with Customer Service, Provider Relations, Configuration, Pricing, Compliance, and other business partners to resolve claim issues and escalations.
• Identify, research, and escalate system, configuration, pricing, benefit, or process issues timely and with clear supporting detail.
• Apply current desktop procedures, benefit documents, claims policies, and training resources to ensure consistent and compliant claim handling.
• Meet established productivity, quality, timeliness, and attendance expectations while supporting member and provider satisfaction.
• Support assigned reports, member reimbursement requests, special projects, and other departmental responsibilities as needed.
• Model accountability, collaboration, inclusion, and a people-first approach in daily work and cross-functional interactions.
• Other duties as required.

Qualifications

• Education: Associate’s degree preferred.
• Experience: At least 2-3 years of healthcare claims experience required.
• Knowledge of medical billing and coding principles, reimbursement methodologies, and insurance claim submission processes.
• Knowledge of healthcare regulations and compliance requirements, including HIPAA guidelines.
• Familiarity with Medicare, Medicaid, government programs, and applicable billing requirements.
• Strong attention to detail and accuracy in claim submissions, research, documentation, and recordkeeping.
• Excellent written and verbal communication skills to interact effectively with insurance companies, providers, members, patients, and colleagues.
• Strong customer service orientation and ability to handle sensitive or difficult situations with empathy, professionalism, and sound judgment.

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: $19.81 - $28.30/Hourly.
• Grade: 3.

Benefits

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