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Claims Review Specialist, Medicare Advantage

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Nov 04, 2025
This is a remote role that can be done in most U.S. states. The Medicare Advantage Claims Review Specialist processes Medicare Advantage claims that do not auto adjudicate through the claim system adhering to Mass General Brigham Health Plan's current administrative policies, procedures, and clinical guidelines. Principal Duties and Responsibilities: * Adjudicate claims to pay, deny, or pend as appropriate in a timely and accurate manner according to company policy and desktop procedure. * Review and research assigned claims by navigating multiple systems and platforms, then accurately capturing the data/information necessary for processing (e.g., verify pricing/fee schedules, contracts, Letter of Agreement, prior authorization, applicable member benefits). * Manually enters claims into claims processing system 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, procedures, benefits plan documents). * Communicate and collaborate with external department to resolve claims errors/issues, using clear and concise language to ensure understanding. * Learn and leverage new systems and training resources to help apply claims processes/procedures appropriately (e.g., online training classes, coaches/mentors). * Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction. * Create/update work within the call tracking record keeping system. * Adhere to all reporting requirements. * 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. Qualifications: High School Diploma At least 1-2 years of healthcare billing experience required At least 2-3 years of previous experience in the health insurance industry in functions such as hospital or physician biller, call center experience, previous claims processing, or similar industry experience highly preferred Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes highly preferred Knowledge of medical terminology highly preferred Knowledge of claim forms (professional and facility) highly preferred Knowledge of paper vs. electronic filing and medical billing guidelines preferred Completion of coding classes from certified medical billing school Professional Coder Certificate is highly desirable Knowledge of Medicare or Medicare Advantagehighly preferred Working Conditions This is a remote role that can be done from most US states On remote workdays, employees must use a stable, secure, and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment. Mass General Brigham Health Plan Holding Company, Inc. 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 law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.