Third Party Reviewer

Mass General Brigham•Somerville, MA

5h•Remote

About The Position

Responsible for conducting thorough and accurate reviews of healthcare billing and claims documentation. This role involves ensuring accuracy, completeness, and compliance with regulatory requirements, coding guidelines, and payer policies. The reviewer will verify the appropriateness of billed services, identify compliance issues, and evaluate clinical documentation. Collaboration with healthcare providers and billing teams is essential for resolving discrepancies and preventing future claim denials. The role also includes identifying and reporting potential fraudulent activities.

Requirements

High School Diploma or Equivalent required
Experience in medical billing, claims processing, or coding within a healthcare environment, with a strong focus on third-party payer guidelines and regulations.
1-2 years preferred
In-depth knowledge of coding systems (e.g., ICD-10-CM, CPT, HCPCS) and billing requirements across various healthcare settings.
Familiarity with billing and coding compliance regulations, such as 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 in using 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, HIPPA-compliant workstation is required.

Responsibilities

Review medical claims and billing documentation to ensure 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 to ensure adherence to industry regulations, such as HIPAA and CMS guidelines.
Evaluate the accuracy and adequacy of clinical documentation, ensuring it supports the billed services and complies with medical necessity guidelines.
Collaborate with healthcare providers to obtain additional information or clarification, if necessary.
Analyze claim denials and rejections, identify root causes, and recommend corrective actions to prevent future denials.
Work closely with billing and coding teams to resolve claim discrepancies and resubmit claims, if 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.