Medicare Advantage Claims Review Specialist

Mass General Brigham Health Plan; Somerville (MA); On-site; USD 45,000 - 60,000; Full time

Job summary

A healthcare organization in Somerville is looking for a Medicare Advantage Claims Review Specialist. The role involves processing claims, ensuring accurate benefits application, and resolving issues while adhering to company policies. Ideal candidates will have experience in health insurance, strong attention to detail, and the ability to work effectively in a team. This position offers a chance to contribute to member and provider satisfaction.

Qualifications

• 2-3 years in the health insurance industry or similar experience.
• Demonstrated competency in data entry.
• Basic math and language skills.

Responsibilities

• Adjudicate claims to pay, deny, or pend accurately.
• Review and research claims across multiple systems.
• Process member reimbursement requests as needed.

Skills

Attention to detail

Problem solving

Time management

Communication

Teamwork

Education

High School Diploma or equivalent experience

Pharmacy Technician certification

Job description

Job Description:

The Medicare Advantage Claims Review Specialist processes claims that do not auto adjudicate through the claim system adhering to Mass General Brigham Health Plan's current administrative policies, procedures, and clinical guidelines.

Primary Responsibilities:

• 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.
• Manually enters claims into claims processing system as needed.
• Ensure that the proper benefits are applied to each claim by using the appropriate processes and desktop procedures.
• Communicate and collaborate with external department to resolve claims errors/issues, using clear and concise language to ensure understanding.
• Learn and leverage new systems and training resources to help apply claims processes/procedures appropriately.
• Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction.
• Create/update work within the call tracking record-keeping system.
• Adhere to all reporting requirements.
• Keep up to date with Desktop Procedures and effectively apply this knowledge in the processing of claims and in providing customer service.
• Process member reimbursement requests as needed.
• Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner.
• Interprets contracts and edit steps correctly and applies to processing.

Basic Requirements:

• High School Diploma or equivalent experience
• Pharmacy Technician certification is preferred but not required
• 2-3 years of previous experience in the health insurance industry in functions such as hospital or physician biller, call center experience, previous claims processing, or similar industry experience
• Attention to detail, decision making problem solving, time management and organizational skills, communication and teamwork.
• Basic math and language skills
• Demonstrated competency in data entry

Preferred Qualifications:

• Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes.
• Knowledge of medical terminology
• Knowledge of claim forms (professional and facility)
• Knowledge of paper vs. electronic filing and medical billing guidelines preferred
• Completion of coding classes from certified medical billing school
• Professional Coder Certificate is highly desirable

EEO Statement

Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. 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 the law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, perform essential job functions, and receive other benefits and privileges of employment.