Claims Review Specialist

Mass General Brigham•Somerville, MA

1d•Remote

About The Position

The Claims Review Specialist evaluates medical claims submitted by healthcare providers, insurance companies, and patients to ensure proper coding, documentation, and compliance with billing regulations. The role reviews claims for discrepancies, errors, and potential fraud; validates diagnosis and procedure codes; checks supporting medical records; and compares claim payments with contracted rates, fee schedules, and industry benchmarks. The specialist also conducts audits, identifies payment or billing errors, and stays current with payer policies and reimbursement rules. This is a full-time remote role available 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 requirements may be verified under organizational policy.

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 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.
For remote work, maintain a stable internet connection and a secure, private, quiet workspace appropriate for handling confidential and protected health information.

Nice To Haves

Associate's degree.
At least two to three years of previous experience in the health insurance industry, 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 to ensure accurate representation of healthcare services provided.
Verify that claims include complete and accurate documentation supporting the services rendered, 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.