Third Party Reviewer

Site: Mass General Brigham Incorporated 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 Responsible for conducting thorough and accurate reviews of healthcare billing and claims documentation. Essential Functions Review medical claims and billing documentation to ensure accuracy, completeness, and compliance with regulatory requirements, coding guidelines, and payer policies. Verify the appropriateness of billed services, procedures, and diagnosis codes. Identify potential compliance issues, including incorrect coding, unbundling, upcoding, and other billing irregularities. Conduct audits to ensure adherence to industry regulations, such as HIPAA and CMS guidelines. Evaluate the accuracy and adequacy of clinical documentation, ensuring it supports the billed services and complies with medical necessity guidelines. Collaborate with healthcare providers to obtain additional information or clarification, if necessary. Analyze claim denials and rejections, identify root causes, and recommend corrective actions to prevent future denials. Work closely with billing and coding teams to resolve claim discrepancies and resubmit claims, if needed. Identify potential fraudulent activities or abuse in billing practices. Report suspicious activities and work with internal compliance teams and external agencies to investigate and resolve fraud cases. Qualifications Education High School Diploma or Equivalent required Experience Experience in medical billing, claims processing, or coding within a healthcare environment, with a strong focus on third-party payer guidelines and regulations. 1-2 years preferred Knowledge, Skills and Abilities In-depth knowledge of coding systems (e.g., ICD-10-CM, CPT, HCPCS) and billing requirements across various healthcare settings. Familiarity with billing and coding compliance regulations, such as HIPAA, CMS guidelines, and National Correct Coding Initiative (NCCI) edits. Strong analytical skills and attention to detail, with the ability to review and interpret complex billing and coding documentation. Proficiency in using billing software and electronic health record (EHR) systems. Excellent communication and interpersonal skills, with the ability to collaborate effectively with internal teams, healthcare providers, and insurance companies. Additional Job Details (if applicable) Monday through Friday Eastern business hours are required for this remote position. Following training, scheduled shifts will fall between 6:00 AM and 6:00 PM EST. The training schedule will be conducted Monday through Friday between 8:00 AM and 6:00 PM EST. A quiet, secure, and reliable HIPAA-compliant workspace is required to perform this role effectively. Remote Type Hybrid Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $19.81 - $28.30/Hourly Grade 3 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. EEO Statement: 0100 Mass General Brigham Incorporated 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. #J-18808-Ljbffr Mass General Brigham