Remote Medicare Advantage Claims Specialist

Mass General Brigham (Enterprise Services); Somerville (MA); On-site; USD 25,000 - 34,000; Full time

Job summary

Mass General Brigham Health Plan is seeking a Medicare Advantage Claims Review Specialist to adjudicate and process complex requests, ensuring accuracy and compliance. This remote role supports our nationwide operations with standard 40-hour work weeks and ET-friendly hours.

The ideal candidate has hands-on Medicare claims processing experience and proficiency with QNXT or similar adjudication systems. Strong attention to detail and customer service skills are essential.

Qualifications

• High School Diploma or equivalent required; Associate's degree preferred.
• 1–2 years related healthcare experience required.
• 2–3 years health insurance industry experience preferred.
• Medicare claims processing experience preferred.
• Knowledge of medical billing and coding principles, reimbursement methodologies, and insurance claim submission processes.
• HIPAA compliance knowledge and understanding of healthcare regulations.

Responsibilities

• Adjudicate claims to pay, deny, or pend per policy and procedures.
• Review and research claims across systems, capture required data.
• Manually enter claims into processing system as needed.
• Ensure benefits are properly applied per policy documents.
• Communicate with external departments to resolve issues.
• Learn and apply new systems and training resources for claims processes.

Skills

Attention to detail

Communication skills

Customer service orientation

Empathy

Education

High School Diploma or equivalent

Tools

QNXT

Facets

Job description

Mass General Brigham Health Plan is seeking a Medicare Advantage Claims Review Specialist to adjudicate and process complex requests, ensuring accuracy and compliance. This remote role supports our nationwide operations with standard 40-hour work weeks and ET-friendly hours.

The ideal candidate has hands-on Medicare claims processing experience and proficiency with QNXT or similar adjudication systems. Strong attention to detail and customer service skills are essential.