This is a hybrid role requiring an onsite presence to the Somerville office 1x/month.
The Claims Resolution Coordinator reviews all provider correspondence and inquiries from Customer Service for Medicaid claims and then determines the need for claims adjustment. S/he processes provider correspondence efficiently while adhering to timelines and Mass General Brigham Health Plan guidelines utilizing independent decision-making skills as appropriate when adjusting Medicaid claims.
Primary Responsibilities:
Review and research assigned claims by navigating multiple systems and platforms and accurately capturing the data/information necessary for processing (e.g. verify pricing/Fee Schedules, contracts and Letters of Agreement, prior authorizations, applicable member benefits)
Pay, deny, or pend claims as appropriate in a timely and accurate manner
Manually enters claims into QNXT 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 and procedures, benefit plan documents/ certificates)
Create/update, work, and close Call tracking records in the QNXT call tracking module.
Adhere to all reporting requirements communicate and collaborate with other departments to resolve claims errors/issues, using clear, simple 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 the areas of production, accuracy, quality, member and Provider satisfaction, and attendance
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
Hold self and others accountable to meet commitments.
Ensure diversity, equity, and inclusion are integrated as a guiding principle.
Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise
Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
Qualifications
Required:
At least 3-5 years of previous experience in the healthcare insurance industry in functions such as hospital or physician biller or call center
Previous claims processing or similar industry experience with
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.
Knowledge of medical billing guidelines.
Preferred/Desired:
Completion of coding classes from a certified medical billing school
Knowledge of Government Sponsored programs
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.
