Key Facts

Remote From:

Full time

Mid-level (2-5 years)

English

Hard Skills

Call Recording Contract Management Cross-Platform Applications Developing Training Materials Prior Authorization Claims And Litigation Management Patent Applications ICD 503 Cppunit Medical Abbreviations Problem Management

Other Skills

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Report Writing
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Decision Making
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Professionalism
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Communication
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Adaptability
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Time Management
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Teamwork
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Customer Service
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Empathy

Roles & Responsibilities

High School Diploma required; Associate's Degree in Healthcare Management preferred.
1-2 years of related healthcare experience required; 2-3 years in the health insurance industry highly preferred (hospital/physician billing, call center, claims processing).
SCO and OneCare claims processing experience highly preferred.
Knowledge of healthcare claims processes for D-SNP/Medicare/Medicaid/Mass Health; ICD-10, HCPCS, CPT-4, and Revenue Codes; familiarity with billing requirements; professional coder certificate desirable.

Requirements:

Adjudicate claims to pay, deny, or pend as appropriate in a timely and accurate manner according to company policy and desktop procedures.
Review and research assigned claims across multiple systems, verify pricing/fee schedules, contracts, prior authorizations, and member benefits, and capture necessary data.
Manually enter claims into the processing system when required and ensure proper benefits are applied.
Communicate and collaborate with internal/external departments to resolve claim errors/issues, and escalate system or pricing issues as needed while meeting performance goals.

Brigham and Women's Hospital

About Brigham and Women's Hospital

Boston's Brigham and Women's Hospital (BWH) is an international leader in virtually every area of medicine and has been the site of pioneering breakthroughs that have improved lives around the world. A major teaching hospital of Harvard Medical School, BWH has a legacy of excellence that continues to grow. With two outstanding hospitals, over 150 outpatient practices, and over 1,200 physicians, we serve patients from New England, throughout the United States, and from 120 countries around the world. The BWH name is a reflection of our history. In 1980 three of Boston’s oldest and most prestigious Harvard Medical School teaching hospitals - the Peter Bent Brigham Hospital, the Robert Breck Brigham Hospital, and the Boston Hospital for Women – merged to form Brigham and Women’s Hospital. As a national leader in improving health care quality and safety, we have helped to develop some of the industry’s best practices including computerized physician order entry (CPOE) to prevent medication errors. The CPOE is now a nationally-accepted safety practice. The BWH Biomedical Research Institute (BRI) is one of the most powerful biomedical research institutes in the world and the second largest recipient of National Institutes of Health (NIH) funding among independent hospitals in the United States. BWH has long had great success in research as measured by the number of important discoveries made, the size and scope of its research portfolio and the volume of publications annually. BWH is a training ground for physicians, nurses, and allied health professionals. We have 1,100 trainees in over 140 of the most sought after training programs in the world, and also host Harvard Medical School students in rotations throughout our programs. As our global health services expand, our clinical trainees have rich opportunities to contribute and learn in challenging environments around the world. Brigham and Women's Hospital is an EEO, AA, VEVRAA Employer.

Founded: 2018

Company size: 10001

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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.

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 Summary

The D‑SNP Claims Review Specialist reviews and processes Senior Care Options (SCO) and One Care medical claims requiring manual intervention when auto‑adjudication is not achieved. The Specialist ensures claims are adjudicated accurately, timely, and in compliance with Mass General Brigham Health Plan administrative policies, operational procedures, and clinical guidelines. The ideal candidate brings hands‑on experience with SCO and One Care claims processing and demonstrated proficiency in QNXT or similar claims adjudication systems (e.g., Facets).

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

Education

High School Diploma required and Associate's Degree Healthcare Management preferred

Experience

Related Healthcare Experience 1-2 years 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, claims processing, or similar industry experience highly preferred.
SCO and OneCare claims processing experience highly preferred

Knowledge, Skills, and Abilities

Knowledge of healthcare claims processes for (D-SNP/fully-integrated Medicare & Medicaid/Mass Health highly preferred.
Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes highly preferred
Knowledge of medical terminology highly preferred.
Familiarity with insurance plans, government programs, and their billing requirement preferred.
Knowledge of claim forms (professional and facility) highly preferred
Professional Coder Certificate is highly desirable
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 remote role that can be done
This is a full-time schedule (8-4:30 pm or 8:30-5:00 pm ET)

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$17.71 - $25.28/Hourly

Grade

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.

EEO Statement:

8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

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.

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