Note: The job is a remote job and is open to candidates in USA. Mass General Brigham is a leading integrated healthcare system dedicated to providing exceptional care. The ACO Medicaid Claims Review Specialist will review and adjudicate claims to ensure accurate coding, compliance with billing regulations, and resolve claims errors, all while contributing to an exceptional member experience.
Responsibilities
- Review claims to ensure accurate coding, appropriate documentation, and compliance with applicable billing regulations and payer guidelines
- 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 (e.g., verify pricing/fee schedules, contracts, prior authorization, applicable member benefits)
- Communicate and collaborate with external departments to resolve claims errors/issues, using clear and concise language to ensure understanding
- Review and adjudicate 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 services rendered and compliance with coding standards
- Keep up to date with Desktop Procedures and effectively apply this knowledge in the processing of claims and in providing customer service
- Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner
- Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records
- Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction
Skills
- High School Diploma or Equivalent required
- At least 1-2 years of healthcare billing experience required
- Knowledge of Medicaid/ACO claims processing
- Knowledge of claim types including professional, facility, DME, outpatient, and inpatient
- Ability to prioritize and manage aged claims (e.g., 30+ day inventory) to meet program guidelines and turnaround requirements
- Strong attention to detail and accuracy in claim review, submissions, and documentation
- 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
- Associate's Degree preferred
- Professional Coder (CPC) license preferred
- At least 2–4 years of experience in healthcare claims processing, billing, or the health insurance industry (e.g., hospital or physician billing) highly preferred
- Experience with core healthcare claims processing and billing system highly preferred
- Strong working knowledge of managed care concepts and medical coding, including ICD-10, CPT, HCPCS, and Revenue Codes highly preferred
Benefits
- Competitive salaries
- Benefits package with flexible work options
- Career growth opportunities
- Comprehensive benefits
- Differentials
- Premiums and bonuses
Company Overview
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