Claims Review Specialist, Medicare Advantage

Mass General Brigham•Somerville, MA

1d•$18 - $25•Remote

About The Position

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. The Medicare Advantage Claims Review Specialist reviews and processes Medicare Advantage medical claims requiring manual intervention when auto‑adjudication is not achieved in QNXT. The Specialist ensures claims are adjudicated accurately, timely, and in compliance with Mass General Brigham Health Plan administrative policies, operational procedures, and clinical guidelines. The ideal candidate brings hands‑on experience with Medicare Advantage claims processing and demonstrated proficiency in QNXT or similar claims adjudication systems (e.g., Facets).

Requirements

High School Diploma or Equivalent required
Related Healthcare Experience 1-2 years required
At least 2-3 years of previous experience in the health insurance industry in functions such as claims processing highly preferred.
Medicare claims processing experience highly preferred
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.
Strong attention to detail and accuracy in claim submissions and recordkeeping.
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.

Nice To Haves

Associate's Degree preferred

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 (e.g., verify pricing/fee schedules, contracts, Letter of Agreement, prior authorization, applicable member benefits).
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 (e.g., claims processing policies, procedures, benefits plan documents).
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 (e.g., online training classes, coaches/mentors).
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.
Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner.
Process member reimbursement requests as needed.