DSNP Claims Resolution Coordinator

Mass General Brigham•Somerville, MA

1d•$20 - $28•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 DSNP Claims Resolution Coordinator is responsible for reviewing, researching, and resolving Dual Eligible Special Needs Plan (DSNP) claim inquiries, provider correspondence, and escalations received through Customer Service and internal business partners. This role determines whether claim adjustments are needed, applies Medicare and Medicaid benefit and payment guidelines, and ensures claims are processed accurately, timely, and in accordance with Mass General Brigham Health Plan policies, contractual requirements, and regulatory expectations. The coordinator uses independent judgment, strong analytical skills, and cross-functional collaboration to identify claim issues, support resolution, and help improve the member and provider experience.

Requirements

Associate’s degree preferred.
At least 2-3 years of healthcare claims experience required
Knowledge of medical billing and coding principles, reimbursement methodologies, and insurance claim submission processes.
Knowledge of healthcare regulations and compliance requirements, including HIPAA guidelines.
Familiarity with Medicare, Medicaid, government programs, and applicable billing requirements.
Strong attention to detail and accuracy in claim submissions, research, documentation, and recordkeeping.
Excellent written and verbal communication skills to interact effectively with insurance companies, providers, members, patients, and colleagues.
Strong customer service orientation and ability to handle sensitive or difficult situations with empathy, professionalism, and sound judgment.

Responsibilities

Review, research, and resolve assigned DSNP claim inquiries, provider correspondence, and escalations using QNXT and other internal systems.
Determine appropriate claim action, including payment, denial, adjustment, manual entry, or pending for additional review, in accordance with applicable Medicare and Medicaid guidelines.
Validate benefits, authorizations, pricing, fee schedules, contracts, Letters of Agreement, and member eligibility to support accurate and timely claim resolution.
Maintain accurate documentation in applicable tracking systems, including call tracking records, claim notes, reports, and reimbursement request records.
Communicate and collaborate with Customer Service, Provider Relations, Configuration, Pricing, Compliance, and other business partners to resolve claim issues and escalations.
Identify, research, and escalate system, configuration, pricing, benefit, or process issues timely and with clear supporting detail.
Apply current desktop procedures, benefit documents, claims policies, and training resources to ensure consistent and compliant claim handling.
Meet established productivity, quality, timeliness, and attendance expectations while supporting member and provider satisfaction.
Support assigned reports, member reimbursement requests, special projects, and other departmental responsibilities as needed.
Model accountability, collaboration, inclusion, and a people-first approach in daily work and cross-functional interactions.
Other duties as required.