Medicare Advantage Claims Review Specialist

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Medicare Advantage Claims Review Specialist

- (3271103) This is a hybrid role requiring an onsite presence in the office in Assembly Row, Somerville one day each quarter and when employees have connectivity issues. The Medicare Advantage Claims Review Specialist processes 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. Primary Responsibilities: The Medicare Advantage Claim Reviewer is responsible for the adjudication of claims adhering to Mass General Brigham Health Plan current administrative policies and procedures, clinical guidelines, unbundling software and other system edits. The reviewer will adjudicate the claims by reviewing hospital and/or physician contracts, fee schedules, and current billing guidelines. This requires an in-depth review of authorizations including non-clinical notes and Letters of agreement. In addition, this position also requires problem resolution skills and judgment skills to determine the appropriate staff to assist with the resolution, depending on the issue (i.e. contracting, configuration, IT, Supervisor).

• 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.
• Process member reimbursement requests as needed.
• Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner.
• Process member reimbursement requests as needed.
• Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner.
• Interprets contracts and edit steps correctly and applies to processing.

Basic Requirements:

• High School Diploma or equivalent experience
• Pharmacy Technician certification is preferred but not required
• 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
• Attention to detail, decision making problem solving, time management and organizational skills, communication and teamwork.
• Basic math and language skills
• Demonstrated competency in data entry

Preferred Qualifications:

• 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 and medical billing guidelines preferred
• Completion of coding classes from certified medical billing school
• Professional Coder Certificate is highly desirable

Preferred Experience:

• Knowledge of Medicare or Medicare Advantage

EEO Statement

Mass General Brigham 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 the law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, perform essential job functions, and receive other benefits and privileges of employment.

Primary Location MA-Somerville-MGB Assembly Row Work Locations MGB Assembly Row 399 Revolution Drive Somerville 02145 Job Admin/Clerical/Cust Service Organization Mass General Brigham Health Plan Schedule Full-time Standard Hours 40 Shift Day Job Posted Shift Description Hybrid position with traditional 9:00am-5:00pm business hours Employee Status Regular Recruiting Department MGB Health Plan Human Resources Job Posting Dec 21, 2025