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Claims Review Specialist

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Apr 09, 2025
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. Education High School Diploma or Equivalent required and Associate's Degree Healthcare Management preferred Can this role accept experience in lieu of a degree? No Experience At least 1-2 years of healthcare Billing Experience required Knowledge, Skills and Abilities 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. This is a full-time role with a 8:30-5 schedule This is a remote role that can be done from most US states Physical Requirements Standing Occasionally (3-33%) Walking Occasionally (3-33%) Sitting Constantly (67-100%) Lifting Occasionally (3-33%) 20lbs - 35lbs Carrying Occasionally (3-33%) 20lbs - 35lbs Pushing Rarely (Less than 2%) Pulling Rarely (Less than 2%) Climbing Rarely (Less than 2%) Balancing Occasionally (3-33%) Stooping Occasionally (3-33%) Kneeling Rarely (Less than 2%) Crouching Rarely (Less than 2%) Crawling Rarely (Less than 2%) Reaching Occasionally (3-33%) Gross Manipulation (Handling) Constantly (67-100%) Fine Manipulation (Fingering) Frequently (34-66%) Feeling Constantly (67-100%) Foot Use Rarely (Less than 2%) Vision - Far Constantly (67-100%) Vision - Near Constantly (67-100%) Talking Constantly (67-100%) Hearing Constantly (67-100%) 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.