ACO Medicaid Claims Review Specialist

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 elevate 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. 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. 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 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. #J-18808-Ljbffr Mass General Brigham Health Plan