ACO Medicaid Claims Review Specialist
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Job Location:
Somerville, NJ - USA
Hourly Salary:
$ 17 - 24
Posted on:
12 hours ago
Vacancies:
1 Vacancy
Job Summary
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 on the forefront of transformation with one of the worlds 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.We are pleased to offer competitive salaries and a benefits package with flexible work options career growth opportunities and much more.
Job Description Summary
Review claims to ensure accurate coding appropriate documentation and compliance with applicable billing regulations and payer guidelines.
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 prior authorization applicable member benefits).
Communicate and collaborate with external departments to resolve claims errors/issues using clear and concise language to ensure understanding.
Review and adjudicate medical claims submitted by healthcare providers insurance companies and patients to identify discrepancies errors or potential fraud.
Analyze and validate the assigned diagnosis codes (ICD-10) and procedure codes (CPT) on medical claims to ensure accurate representation of services rendered and compliance with coding standards.
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 a timely manner.
Ensure that the medical claims include complete and accurate documentation supporting the services rendered including physician notes test results and other relevant records.
Meet the performance goals established for the position in areas of productivity accuracy and attendance that drives member and provider satisfaction.
Qualifications
Education
- High School Diploma or Equivalent required
- Associates Degree preferred
Licenses and Credentials
- Professional Coder (CPC) license preferred
Experience
- At least 1-2 years of healthcare billing experience required
- At least 24 years of experience in healthcare claims processing billing or the health insurance industry (e.g. hospital or physician billing) highly preferred
- Experience with core healthcare claims processing and billing system highly preferred
- Strong working knowledge of managed care concepts and medical coding including ICD-10 CPT HCPCS and Revenue Codes highly preferred
Knowledge Skills and Abilities
- Knowledge of Medicaid/ACO claims processing
- Knowledge of claim types including professional facility DME outpatient and inpatient
- Ability to prioritize and manage aged claims (e.g. 30 day inventory) to meet program guidelines and turnaround requirements
- Strong attention to detail and accuracy in claim review submissions and documentation
- 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 professionalism.
Additional Job Details (if applicable)
Working Conditions
This is a full-time role with a Monday through Friday 8:30-5 schedule
This is a remote role that can be done from most US states
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$17.36 - $24.79/HourlyGrade
2EEO Statement:
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.
Required Experience:
IC
Key Skills
- Corporate Paralegal
- Baan
- IT Sales and Marketing
- Civil Quality Control
- Activex
- Jboss
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
