Remote Medicare Advantage Claims Specialist

Mass General Brigham Health Plan, Inc.; Somerville (MA); Remote; USD 25,000 - 34,000; Full time

Job summary

Mass General Brigham Health Plan is seeking a Medicare Advantage Claims Review Specialist to process and adjudicate complex Medicare claims when autoadjudication isn’t achieved. The role requires familiarity with QNXT or similar adjudication systems and strict adherence to policies and guidelines.

The position is remote and involves reviewing claims, applying correct benefits, and collaborating with multiple departments to resolve issues while maintaining high accuracy and compliance standards.

Qualifications

• Knowledge of medical billing and coding principles and claim submission processes.
• Familiarity with healthcare regulations and HIPAA guidelines.
• Experience in health insurance claims processing preferred.

Responsibilities

• Adjudicate claims to pay, deny, or pend per policy.
• Research claims across systems and capture necessary data for processing.
• Enter claims manually when needed.
• Ensure proper benefits are applied per plan documents.
• Collaborate with external departments to resolve claim issues.
• Learn new systems and apply procedures through training resources.
• Meet performance goals for productivity, accuracy and attendance.
• Maintain and update call tracking records.
• Adhere to reporting requirements.
• Identify and escalate system and pricing issues promptly.

Skills

Medicare claims processing

Data accuracy

Communication skills

HIPAA knowledge

Education

High School Diploma or equivalent

Associate's Degree preferred

Tools

QNXT

Facets

Job description

Mass General Brigham Health Plan is seeking a Medicare Advantage Claims Review Specialist to process and adjudicate complex Medicare claims when autoadjudication isn’t achieved. The role requires familiarity with QNXT or similar adjudication systems and strict adherence to policies and guidelines.

The position is remote and involves reviewing claims, applying correct benefits, and collaborating with multiple departments to resolve issues while maintaining high accuracy and compliance standards.