Claims Review Specialist, DSNP at Massgeneralbrigham
Massgeneralbrigham · Somerville, Estados Unidos Da América · Remote
- Professional
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
The D-SNP Claims Review Specialist processes Senior Care Options and One Care medical claims that do not auto-adjudicate through the claim system, adhering to Mass General Brigham Health Plan’s current administrative policies, procedures, and clinical guidelines.Principal Duties and 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., online 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
Qualifications:
High School Diploma
At least 1-2 years of healthcare billing experience 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 highly preferred
Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes highly preferred
Knowledge of medical terminology highly preferred
Knowledge of claim forms (professional and facility) highly preferred
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
Knowledge of Medicare/Medicaid OR DSNP plans highly preferred
Additional Job Details (if applicable)
Working Conditions
- This is a remote role that can be done from most US states
- Employees must use a stable, secure, and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$17.36 - $24.79/Hourly
Grade
2
EEO Statement:
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.
