This is a hybrid role that will require an onsite presence to the office in Somerville, MA once each month.

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.

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 consciously inclusive environment where diversity is celebrated.

We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.

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 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 Call tracking records in QNXT 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, quality, member and Provider satisfaction and attendance.
• 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.

Knowledge and Education

Required:

• High School Diploma or equivalent

Experience:

Required:

• 3-5 years of previous experience in the healthcare insurance industry in functions such as hospital or physician biller or call center
• Previous claims processing or similar industry experience with
  • 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/Desired:

• • Completion of coding classes from certified medical billing school

Competencies:

• Demonstrate Mass General Brigham Health Plan core brand principles of always listening, challenging conventions, and providing value.
• Strong aptitude for technology-based solutions.
• Ability to inject energy, when and where it's needed.
• Respect the talent and unique contribution of every individual and treat all people in a fair and equitable manner.
• Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
• Be accountable for delivering high-quality work. Act with a clear sense of ownership.
• Bring fresh ideas forward by actively listening to and working with employees and the people we serve.

Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. 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 the law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, perform essential job functions, and receive other benefits and privileges of employment.