Claims Review Specialist

Site: Mass General Brigham Health Plan Holding Company, Inc. At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission—from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve. At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare — people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds – to apply. Job Summary This is a hybrid role requiring an onsite presence in the Somerville office 1x/month. The Claims Review Specialist processes claims that do not auto adjudicate through the claim system adhering to Mass General Brigham Health Plan current administrative policies, procedures, and clinical guidelines. Primary Responsibilities: -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., on-line 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 Basic Requirements: High School Diploma or equivalent experience Pharmacy Technician certification is required At least 2-3 years of previous experience in the health insurance industry in functions such as hospital or physician biller, call center experience, previous claims processing, or similar industry experience Attention to detail, decision making problem solving, time management and organizational skills, communication and teamwork. Basic math and language skills Demonstrated competency in data entry Preferred Qualifications: Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes. Knowledge of medical terminology Knowledge of claim forms (professional and facility) Knowledge of paper vs. electronic filing and medical billing guidelines preferred Completion of coding classes from certified medical billing school Professional Coder Certificate is highly desirable About Us: Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on 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 consciously inclusive environment where diversity is celebrated. We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more. Additional Job Details (if applicable) Additional Job Description Remote Type Hybrid Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) EEO Statement: Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline. Combat disease. Hold a hand. Help people. Impact the world. Mass General Brigham is a passionate, welcoming community where minds meet caring hearts. Come be a part of the world’s most powerful force in medicine, where every role is important in changing lives. Are you ready? Our history includes New England hospitals founded over 200 years ago, some of the first and most prestigious hospitals in the world. Built on the legacy of two leading academic medical centers, we’re more than a system—we’re leaders in the practice of medicine. Mass General Brigham is committed to serving the community. We are dedicated to enhancing patient care, teaching and research, and taking a leadership role as an integrated health care system. We recognize that increasing value and continuously improving quality are essential to maintaining excellence.