Third Party Reviewer

Mass General Brigham•Somerville, MA

17h•$20 - $28•Remote

About The Position

The Third Party Reviewer conducts thorough and accurate reviews of healthcare billing and claims documentation. The role verifies billing accuracy and compliance with regulatory requirements, coding guidelines, and payer policies; assesses clinical documentation and medical necessity; and identifies billing irregularities, potential compliance issues, and suspected fraud. The reviewer also analyzes claim denials, recommends corrective actions, and works with providers, billing and coding teams, compliance teams, and external agencies to resolve concerns.

Requirements

High school diploma or equivalent.
Knowledge of coding systems such as ICD-10-CM, CPT, and HCPCS, and billing requirements across various healthcare settings.
Familiarity with billing and coding compliance regulations, including HIPAA, CMS guidelines, and National Correct Coding Initiative (NCCI) edits.
Strong analytical skills and attention to detail, with the ability to review and interpret complex billing and coding documentation.
Proficiency with billing software and electronic health record (EHR) systems.
Excellent communication and interpersonal skills, with the ability to collaborate effectively with internal teams, healthcare providers, and insurance companies.
A quiet, secure, stable, HIPAA-compliant workstation is required for the remote role.

Nice To Haves

One to two years of experience in medical billing, claims processing, or coding in a healthcare environment, with a strong focus on third-party payer guidelines and regulations.

Responsibilities

Review medical claims and billing documentation for accuracy, completeness, and compliance with regulatory requirements, coding guidelines, and payer policies.
Verify the appropriateness of billed services, procedures, and diagnosis codes.
Identify potential compliance issues, including incorrect coding, unbundling, upcoding, and other billing irregularities.
Conduct audits for adherence to industry regulations, including HIPAA and CMS guidelines.
Evaluate clinical documentation for accuracy and adequacy, ensuring it supports billed services and complies with medical necessity guidelines.
Collaborate with healthcare providers to obtain additional information or clarification when necessary.
Analyze claim denials and rejections, identify root causes, and recommend corrective actions to prevent future denials.
Work with billing and coding teams to resolve claim discrepancies and resubmit claims when needed.
Identify potential fraudulent activities or abuse in billing practices.
Report suspicious activities and work with internal compliance teams and external agencies to investigate and resolve fraud cases.