Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on 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.

The Claims Resolution Coordinator processes reviews all provider correspondence and inquiries from Customer Service then determines the need for claims adjustment. Processing provider correspondence efficiently while adhering to timelines and Mass General Brigham Health Plan guidelines utilizing independent decision-making skills as appropriate when adjusting claims.

Primary Responsibilities:

• Review and research assigned claims by navigating multiple systems and platforms and accurately capturing the data/information necessary for processing (e.g. verify pricing/Fee Schedules, contracts and Letters of Agreement, prior authorizations, applicable member benefits).
• Pay, deny, or pend claims as appropriate in a timely and accurate manner.
• Manually enters claims into QNXT 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 and procedures, benefit plan documents/ certificates).
• Create/update, work and close records using the system call tracking module.
• Adhere to all reporting requirements communicate and collaborate with other departments to resolve claims errors/issues, using clear, simple language to ensure understanding.
• Learn and leverage new systems and training resources to help apply claims processes/procedures appropriately (e.g., on-line training classes, coaches/mentors).
• Meet the performance, goals established for the position in the areas of production, accuracy, and attendance in an effort to drive member and provider satisfaction.
• 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
• Hold self and others accountable to meet commitments.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization

Basic Requirements:

• Associates degree or equivalent experience
• 3-5 years of previous experience in the health insurance industry in functions such as hospital or physician biller, call center experience, previous claims processing, or similar industry experience
• Attention to detail, decision making, problem solving, time management and the ability to multi-task
• Strong written and oral communication skills

Preferred Qualifications:

• Knowledge of Medicaid/ACO claims processing
• Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes
• Knowledge of medical terminology
• Knowledge of claim forms (professional and facility)
• Knowledge of paper vs. electronic filing
• Knowledge of medical billing guidelines preferred
• Pharmacy Technician certification is highly desirable
• Completion of coding classes from certified medical billing school
• Professional Coder Certificate preferable
• Professional Coder Certificate preferable