Claims Review Specialist, Medicare Advantage

Site: Mass General Brigham Incorporated

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.

Job Summary

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 Medicare Advantage Claims Review Specialist reviews and processes Medicare Advantage medical claims requiring manual intervention when auto‑adjudication is not achieved in QNXT. The Specialist ensures claims are adjudicated accurately, timely, and in compliance with Mass General Brigham Health Plan administrative policies, operational procedures, and clinical guidelines. The ideal candidate brings hands‑on experience with Medicare Advantage claims processing and demonstrated proficiency in QNXT or similar claims adjudication systems (e.g., Facets).Principal Duties and Responsibilities:

• Adjudicate claims to pay, deny, or pend as appropriate in a timely and accurate manner according to company policy and desktop procedure.Review and research assigned claims by navigating multiple systems and platforms, then accurately capturing the data/information necessary for processing (e.g., verify pricing/fee schedules, contracts, Letter of Agreement, prior authorization, applicable member benefits).
• Manually enters claims into claims processing system as needed.Ensure that the proper benefits are applied to each claim by using the appropriate processes and desktop procedures (e.g., claims processing policies, procedures, benefits plan documents).
• Communicate and collaborate with external department to resolve claims errors/issues, using clear and concise language to ensure understanding.Learn and leverage new systems and training resources to help apply claims processes/procedures appropriately (e.g., online training classes, coaches/mentors).
• Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction. Create/update work within the call tracking record keeping system.
• Adhere to all reporting requirements.Keep up to date with Desktop Procedures and effectively apply this knowledge in the processing of claims and in providing customer service.
• Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner. Process member reimbursement requests as needed.

  Qualifications

  Education

  • High School Diploma or Equivalent required; Associate's Degree preferred

  Experience

  • Related Healthcare Experience 1-2 years required
  • At least 2-3 years of previous experience in the health insurance industry in functions such as claims processing highly preferred.
  • Medicare claims processing experience highly preferred

  Knowledge, Skills, and Abilities

  • 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 communication skills, both written and verbal, to interact effectively with insurance companies, patients, and colleagues.
  • Strong customer service orientation and ability to handle sensitive or difficult situations with empathy and

  Additional Job Details (if applicable)

  Working Conditions

  • This is a remote role that can be done from most US states
  • This role is 40 hours/week with five 8-hour days, with a typical schedule of 8:30 am to 5:00 pm ET
  • Employees must use a stable, secure, and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment.

  Remote Type

  Remote

  Work Location

  399 Revolution Drive

  Scheduled Weekly Hours

  40

  Employee Type

  Regular

  Work Shift

  Day (United States of America)

  Pay Range

  $17.71 - $25.28/Hourly

  Grade

  2At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

  EEO Statement:

  0100 Mass General Brigham Incorporated is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

  Mass General Brigham Competency Framework

  At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.