DSNP Claims Resolution Coordinator
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
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 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. 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 DSNP Claims Resolution Coordinator is responsible for reviewing researching and resolving Dual Eligible Special Needs Plan (DSNP) claim inquiries provider correspondence and escalations received through Customer Service and internal business partners. This role determines whether claim adjustments are needed applies Medicare and Medicaid benefit and payment guidelines and ensures claims are processed accurately timely and in accordance with Mass General Brigham Health Plan policies contractual requirements and regulatory expectations. The coordinator uses independent judgment strong analytical skills and cross-functional collaboration to identify claim issues support resolution and help improve the member and provider experience.
Primary Responsibilities:
-Review research and resolve assigned DSNP claim inquiries provider correspondence and escalations using QNXT and other internal systems.
-Determine appropriate claim action including payment denial adjustment manual entry or pending for additional review in accordance with applicable Medicare and Medicaid guidelines.
-Validate benefits authorizations pricing fee schedules contracts Letters of Agreement and member eligibility to support accurate and timely claim resolution.
-Maintain accurate documentation in applicable tracking systems including call tracking records claim notes reports and reimbursement request records.
-Communicate and collaborate with Customer Service Provider Relations Configuration Pricing Compliance and other business partners to resolve claim issues and escalations.
-Identify research and escalate system configuration pricing benefit or process issues timely and with clear supporting detail.
-Apply current desktop procedures benefit documents claims policies and training resources to ensure consistent and compliant claim handling.
-Meet established productivity quality timeliness and attendance expectations while supporting member and provider satisfaction.
-Support assigned reports member reimbursement requests special projects and other departmental responsibilities as needed.
-Model accountability collaboration inclusion and a people-first approach in daily work and cross-functional interactions.
-Other duties as required.
Qualifications
Education:
- Associates degree preferred.
Experience:
- At least 2-3 years of healthcare claims experience required
Knowledge Skills and Abilities:
- Knowledge of medical billing and coding principles reimbursement methodologies and insurance claim submission processes.
- Knowledge of healthcare regulations and compliance requirements including HIPAA guidelines.
- Familiarity with Medicare Medicaid government programs and applicable billing requirements.
- Strong attention to detail and accuracy in claim submissions research documentation and recordkeeping.
- Excellent written and verbal communication skills to interact effectively with insurance companies providers members patients and colleagues.
- Strong customer service orientation and ability to handle sensitive or difficult situations with empathy professionalism and sound judgment.
Additional Job Details (if applicable)
Working Conditions
- 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
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.
Required Experience:
IC
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.
