Medicaid Claims Review Specialist

Title: ACO Medicaid Claims Review Specialist

Location: Remote,United States

Full time

Job Description:

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at 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 welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.

We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

Job Description Summary

• Review claims to ensure accurate coding, appropriate documentation, and compliance with applicable billing regulations and payer guidelines.
• 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, prior authorization, applicable member benefits).
• Communicate and collaborate with external departments to resolve claims errors/issues, using clear and concise language to ensure understanding.
• Review and adjudicate medical claims submitted by healthcare providers, insurance companies, and patients to identify 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 services rendered and compliance with coding standards.
• 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.
• Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records.
• Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction.

Qualifications

Education

• High School Diploma or Equivalent required
• Associate's Degree preferred

Licenses and Credentials

• Professional Coder (CPC) license preferred
• Pharmacy Technician certification and/or a degree in a pharmacy-related field preferred

Experience

• At least 1-2 years of healthcare billing experience required
• At least 2-4 years of experience in healthcare claims processing, billing, or the health insurance industry (e.g., hospital or physician billing) highly preferred
• Experience in pharmacy claims processing or adjudication, with a strong working knowledge of pharmacy terminology and National Drug Code (NDC) standards.
• Experience with core healthcare claims processing and billing system highly preferred
• Strong working knowledge of managed care concepts and medical coding, including ICD-10, CPT, HCPCS, and Revenue Codes highly preferred

Knowledge, Skills, and Abilities

• Knowledge of Medicaid/ACO claims processing
• Knowledge of claim types including professional, facility, DME, outpatient, and inpatient
• Ability to prioritize and manage aged claims (e.g., 30+ day inventory) to meet program guidelines and turnaround requirements
• Strong attention to detail and accuracy in claim review, submissions, and documentation
• 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.

Additional Job Details (if applicable)

Working Conditions

• This is a full-time role with a Monday through Friday, 8:30-5 schedule

• This is a remote role that can be done from most US states

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$17.71 - $25.28/Hourly

Grade

2

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.