ACO Medicaid Claims Review Specialist

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. 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 View phone number on click.appcast.io. 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. Combat disease. Hold a hand. Help people. Impact the world. Mass General Brigham is a passionate, welcoming community where minds meet caring hearts. Come be a part of the world’s most powerful force in medicine, where every role is important in changing lives. Are you ready? Our history includes New England hospitals founded over 200 years ago, some of the first and most prestigious hospitals in the world. Built on the legacy of two leading academic medical centers, we’re more than a system—we’re leaders in the practice of medicine. Mass General Brigham is committed to serving the community. We are dedicated to enhancing patient care, teaching and research, and taking a leadership role as an integrated health care system. We recognize that increasing value and continuously improving quality are essential to maintaining excellence.