Claims Review Specialist

8925 Mass General Brigham Health Plan Holding Company, Inc.; Somerville (MA); Remote; USD 24,000 - 35,000; Full time

Job summary

Mass General Brigham Health Plan Holding Company, Inc. is seeking a Claims Review Specialist to assess and audit medical claims for accuracy and compliance.

You will validate ICD-10 and CPT codes, ensure complete documentation, and verify payments against contracts and industry benchmarks. The role emphasizes attention to detail, knowledge of HIPAA, and strong communication with providers, insurers, and patients.

Qualifications

• Knowledge of medical billing and coding principles, reimbursement methodologies, and insurance claim submission processes.
• Knowledge of healthcare regulations and compliance, including HIPAA guidelines.
• 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.

Responsibilities

• Review and assess 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 the services rendered.
• Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records.
• Analyze claim payment amounts and compare them to contracted rates, fee schedules, and industry benchmarks.
• Identify underpayments, overpayments, and potential billing errors.
• Conduct comprehensive audits of medical claims to verify compliance with billing regulations, payer policies, and internal policies and procedures.
• Stay updated on insurance company policies, billing guidelines, and reimbursement rules.

Skills

Medical billing

HIPAA

Attention to detail

Communication skills

Education

High School Diploma or Equivalent

Associate's Degree preferred

Job description

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.

Essential Functions

• Review and assess medical claims submitted by healthcare providers, insurance companies, and patients to identify any 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 the provided healthcare services.
• Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records.
• Analyze claim payment amounts and compare them to contracted rates, fee schedules, and industry benchmarks.
• Identify underpayments, overpayments, and potential billing errors.
• Conduct comprehensive audits of medical claims to verify compliance with billing regulations, payer policies, and internal policies and procedures.
• Stay updated on insurance company policies, billing guidelines, and reimbursement rules.

Qualifications

• Education: High School Diploma or Equivalent required; Associate's Degree preferred.

Experience

• Related Healthcare Experience: 1-2 years required.
• At least 2-3 years of previous experience in the health insurance industry in functions such as claims processing highly preferred.

Knowledge, Skills, and Abilities

• Knowledge of medical billing and coding principles, reimbursement methodologies, and insurance claim submission processes.
• Knowledge of healthcare regulations and compliance, including HIPAA guidelines.
• 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

• Working Condition: This is a full-time role with a Monday through Friday schedule, generally 8:30-5:00 PM Eastern Time.
• Remote work location: Remote. This position is eligible for remote work from approved U.S. locations, subject to organizational requirements. Remote employees must maintain a stable internet connection and a secure, private, quiet workspace appropriate for handling confidential and protected health information. Remote workspace requirements, including privacy and security standards, may be verified in accordance with organizational policy.
• Remote Type: Remote Work.
• 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.

Pay Information

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.

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 (857)-282-7642.

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.

Mission & Culture

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. 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.