Third Party Reviewer
Job Location:
Somerville, NJ - USA
Hourly Salary:
Posted on:
Vacancies:
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
Third Party Claims ReviewerMGB Revenue Cycle Operations supporting Aetna Cigna United Wellpoint Non-Contracted Commercial Team is hiring!
The Teammate is responsible for conducting thorough and accurate reviews of healthcare billing and claims documentation.
-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 potentially 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.
Qualifications
- 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.
- Related experience 1-2 years highly preferred
Skills for Success
- 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.
Additional Job Details (if applicable)
- Remote Work requires secure stable quiet compliant work area and free of dependent care
- M-F Eastern Business hours - shifts may range from 6:00 AM and 6:00 PM EST (required 8.5 hour shifts)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$19.81 - $28.30/HourlyGrade
3EEO 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.
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.
