Fully Remote Claim Processor-Healthcare

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. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

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., 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.

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.

High School Diploma or Equivalent required

Pharmacy Technician certification and/or a degree in a pharmacy-related field preferred

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 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.

Strong customer service orientation and ability to handle sensitive or difficult situations with empathy and professionalism.

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. 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.

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