Claims Review Specialist

Claims Review Specialist

• Meets quality and production claims processing standards
• Independently processes all types of routine claims with minimal assistance, pays, denies, or pends as appropriate in a timely and accurate manner
• Process and price complex Home Infusion claims
• Maintains current knowledge of assigned plan(s) and effectively applies this knowledge in the processing of claims and in providing customer service to internal stakeholders
• Manually enters claims into QNXT as needed
• Ability to review and interpret information from various sources and databases such as Code Check, KCII, Novologix, Optum Fusion and other vendors and software
• Assists other staff with questions pertaining to the processing of claims; directs questions and problems to the appropriate person for resolution
• Process troubleshooter reports as assigned
• Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner
• Interprets contracts and edit steps correctly and applies to processing

• High School Diploma or equivalent experience
• Pharmacy Technician certification is required
• 2-3 years of previous experience in the health insurance industry in functions such as previous claims processing, hospital or physician biller, call center experience working with providers, or similar industry experience
• Attention to detail, decision making problem solving, time management and organizational skills, communication and teamwork.
• Basic math and language skills
• Demonstrated competency in data entry

• Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes.
• Knowledge of medical terminology
• Knowledge of claim forms (professional and facility)
• Knowledge of Home Infusion Claim Processing
• Knowledge of paper vs. electronic filing and medical billing guidelines preferred
• Completion of coding classes from certified medical billing school preferred

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.