Leadership Impact & Problem Solving Actively contributes to the strategic direction for Risk Coding and collaborates with vendor partners to lead volume and ensure adherence to agree upon SLAs. Communicates relevant changes in performance, market trends, health care delivery systems, and legislative initiatives impacting execution of team goals to team(s). Establishes KPI

Review daily, weekly, monthly, quarterly, and yearly CDAG and ODAG reporting to ensure compliance with all Centers for Medicare and Medicaid (CMS) requirements. Develop and maintain CDAG and ODAG reporting for internal teams as well as external auditors Perform data analysis to identify areas of potential non compliance or gaps and collaborate with delegated vendor to upd

Ensures Medicare Advantage CSP guidelines and compliance with CMS regulations Identify trends within the Medicare Advantage team Provide daily direction to team members and ensure their awareness and understanding of information necessary such that calls are answered in a timely, efficient, and knowledgeable manner. Handle all complex customer requests and service failure

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.

Assist with monthly general ledger close, reporting, and general ledger account reconciliations. Deliver timely and accurate financial reporting data to internal and external customers while successfully executing on financial reporting controls. Monitor executing and documenting key controls and policies & procedures, including, but not limited to regulatory filings, man

The Sr. Claims Auditor utilizes CPT and ICD 10 coding to review physician claims and medical records for coding accuracy. Internal auditing functions focus on "desktop reviews" of claims, design and quality control of future audits, and other auditing related functions. Review clinical notes and claims submitted to verify the appropriateness of codes billed based on servi

Provides administrative support to the President, Chief of Staff & Vice President of Corporate Services, and Manager of Program and Administration. Serves as the face of the President's office and professionally represents the President's office when greeting clients and others Manages interdepartmental scheduling for the President and the Chief of Staff & Vice President

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

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

Information Management Developer Leads analysis, design, development, and testing of operational and regulatory reporting for Medicare and Medicaid lines of business. Produces data sets for end users and or regulatory entities. Produces data reconciliation between various data sources to ensure regulatory compliance. Extracts and collects data for performing queries and w

Lead the management of a portfolio of federal regulations, inclusive of policy development, external advocacy work, and gathering internal feedback in support of the advocacy work. Serve as the regulatory subject matter expert on implementation projects impacted by federal guidance and/or regulations. Advise business stakeholders within Mass General Brigham Health Plan on

Establish framework and manage performance for the Appeals and Grievance team aligned with objective to provide best in class service Prioritize and vet a focused set of key performance indicators across the appeals and grievance department including regulatory requirement, best practice indicators, and quality monitoring Establish quality assurance measures to monitor th

Manage and distribute work as designated Run and analyze reports Review aging and inventory levels Hold self and others accountable to meet commitments Assist in testing new processes, system updates and upgrades Identify and provide claim scenarios for testing when needed Assist in the development, implementation, and delivery of training Functions as coach, mentor and r

Use knowledge of healthcare coding conventions to develop and run reports, analyze data to identify suspicious billing patterns, assess the merits of allegations, and present those findings to leadership. Analyze claims data to find suspicious billing patterns and outliers, using knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerabiliti

Leads reserving analysis and communication of financial results to senior leadership. Responsible for developing monthly IBNR, reviewing claims projects, updating lag files, and supporting of other actuarial accruals (MLR Rebate, MassHealth Corridors and Settlements, Risk Adjustment, Cost Sharing Reduction Accrual, etc.) Supports the quarterly forecasting of Mass General