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
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.
EEO Statement
Mass General Brigham Health Plan 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.
