Claims Review Specialist, DSNP

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. 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 D‑SNP Claims Review Specialist reviews and processes Senior Care Options (SCO) and One Care medical claims requiring manual intervention when auto‑adjudication is not achieved. 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 SCO and One Care claims processing and demonstrated proficiency in QNXT or similar claims adjudication systems (e.g., Facets). Essential Functions: • 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 SCO and OneCare claims processing experience highly preferred Knowledge, Skills, and Abilities Knowledge of healthcare claims processes for (D-SNP/fully-integrated Medicare & Medicaid/Mass Health highly preferred. Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes highly preferred Knowledge of medical terminology highly preferred. Familiarity with insurance plans, government programs, and their billing requirement preferred. Knowledge of claim forms (professional and facility) highly preferred Professional Coder Certificate is highly desirable Strong customer service orientation and ability to handle sensitive or difficult situations with empathy and professionalism. Additional Job Details (if applicable) Working Condition This is a remote role that can be done from most US states This is a full-time schedule (8-4:30 pm or 8:30-5:00 pm ET) Remote workdays require a stable, secure, quiet, and compliant workspace ​ 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 2 At 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: 8925 Mass General Brigham Health Plan Holding Company, Inc. 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.