Healthcare Claims Auditor & Compliance

Mass General Brigham Health Plan; Somerville (MA); Remote; USD 20,000 - 29,000; Full time

Job summary

Mass General Brigham Health Plan is seeking a detail-oriented professional to evaluate medical claims for accuracy and adherence to billing regulations. You will validate ICD-10/ CPT coding, ensure complete supporting documentation, and audit payment calculations against contracts and guidelines.

The role requires familiarity with HIPAA, insurance plan requirements, and payer policies, with remote work options available for qualified U.S. locations.

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.

Responsibilities

• 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.

Skills

Medical billing

Medical coding

HIPAA compliance

Attention to detail

Communication skills

Customer service

Education

High School Diploma or Equivalent

Associate's Degree preferred

Job description

Mass General Brigham Health Plan is seeking a detail-oriented professional to evaluate medical claims for accuracy and adherence to billing regulations. You will validate ICD-10/ CPT coding, ensure complete supporting documentation, and audit payment calculations against contracts and guidelines.

The role requires familiarity with HIPAA, insurance plan requirements, and payer policies, with remote work options available for qualified U.S. locations.