Claims Review Specialist

Mass General Brigham•Somerville, MA

1d•$18 - $25•Remote

About The Position

Mass General Brigham Health Plan is part of Mass General Brigham, an integrated healthcare system focused on innovative solutions that expand access to seamless and affordable care and coverage. The organization describes its work environment as welcoming and supportive, with opportunities to learn and contribute expertise. It offers competitive salaries, benefits, flexible work options, and career growth opportunities. The Claims Review Specialist evaluates healthcare claims submitted by providers, insurance companies, and patients to ensure accurate coding and documentation and compliance with billing regulations, payer policies, and internal procedures. The role reviews claim accuracy and payment amounts, identifies discrepancies and potential billing issues, and keeps current with insurance policies and reimbursement rules. This is a full-time remote role from approved U.S. locations, subject to organizational requirements. The schedule is Monday through Friday, generally 8:30 a.m. to 5:00 p.m. Eastern Time, with 40 scheduled hours per week. Remote employees must maintain a stable internet connection and a secure, private, quiet workspace suitable for confidential and protected health information. Workspace privacy and security requirements may be verified under organizational policy. The stated pay range is $17.71–$25.28 per hour.

Requirements

High school diploma or equivalent.
One to two years of related healthcare experience.
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 written and verbal communication skills for interacting 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.
At least two to three years of previous health insurance industry experience, such as claims processing.

Responsibilities

Review and assess medical claims submitted by healthcare providers, insurance companies, and patients for discrepancies, errors, or potential fraud.
Analyze and validate ICD-10 diagnosis codes and CPT procedure codes on medical claims.
Ensure claims have complete and accurate supporting documentation, such as physician notes, test results, and other relevant records.
Analyze claim payment amounts and compare them with contracted rates, fee schedules, and industry benchmarks.
Identify underpayments, overpayments, and potential billing errors.
Conduct comprehensive medical-claim audits to verify compliance with billing regulations, payer policies, and internal policies and procedures.
Stay updated on insurance company policies, billing guidelines, and reimbursement rules.