Supervisor, Medicaid Claims Reviewer

Mass General Brigham•Somerville, MA

2d•$78,000 - $113,454•Remote

About The Position

Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. This role is supervising a team of roughly 5 Medicaid Claims Reviewers. The role is claims inventory management, identifying ACO claims adjudication errors, doing high-dollar reviews, noting claims denial trends, coaching/mentoring team members, and participating in the development of departmental desktop procedures. The ideal candidate has a strong background in Medicaid/ACO claims processing and is a Certified Coder who can understand the difference in different claims edits. Job Summary Responsible for overseeing a team that assesses healthcare claims for accuracy, compliance, and eligibility, ensuring that claims are processed efficiently and in accordance with industry standards, regulatory requirements, and organizational policies. This position will guide and support the claims review team, handle escalations, and collaborate with other departments to improve claims processing and ensure timely reimbursements.

Requirements

Bachelor's degree required (experience can be considered in lieu of degree)
At least 3-5 years of experience in healthcare claims review or processing required
At least 1-2 years of experience in a senior or leadership role required
Strong knowledge of healthcare claims processes, coding (CPT, ICD-10), and payer regulations
Excellent leadership, communication, and problem-solving skills
Proficiency in claims processing software and healthcare management systems
Strong attention to detail and the ability to manage multiple tasks and priorities

Nice To Haves

Certified Professional Coder (CPC) preferred

Responsibilities

Supervise and manage a team of claims reviewers to ensure accurate and timely healthcare claims processing
Oversee claims review and analysis to ensure compliance with healthcare regulations, payer requirements, and organizational policies
Resolve escalated or complex claims issues, ensuring appropriate adjudication and dispute resolution
Monitor team performance, provide feedback, and conduct regular evaluations to support professional growth
Implement and enforce policies and procedures to streamline the claims review process for greater accuracy and efficiency
Collaborate with billing, coding, and compliance teams to ensure adherence to regulatory and payer standards
Analyze claims data to identify trends, address issues, and recommend process improvements
Provide training, guidance, and ongoing education for new and existing team members on industry changes and standards
Performs other duties as assigned
Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records.
Analyze claim payment amounts and compare them to contracted rates, fee schedules, and industry benchmarks.
Identify underpayments, overpayments, and potential billing errors.
Conduct comprehensive audits of medical claims to verify compliance with billing regulations, payer policies, and internal policies and procedures.
Stay updated on insurance company policies, billing guidelines, and reimbursement rules.