Responsible for overseeing a team that assesses healthcare claims for accuracy, compliance, and eligibility, ensuring that claims are processed efficiently and in accordance with industry standards, regulatory requirements, and organizational policies. This position will guide and support the claims review team, handle escalations, and collaborate with other departments to improve claims processing and ensure timely reimbursements.
Essential Functions
- Supervise and manage a team of claims reviewers to ensure accurate and timely healthcare claims processing.
- Oversee claims review and analysis to ensure compliance with healthcare regulations, payer requirements, and organizational policies.
- Resolve escalated or complex claims issues, ensuring appropriate adjudication and dispute resolution.
- Monitor team performance, provide feedback, and conduct regular evaluations to support professional growth.
- Implement and enforce policies and procedures to streamline the claims review process for greater accuracy and efficiency.
- Collaborate with billing, coding, and compliance teams to ensure adherence to regulatory and payer standards.
- Analyze claims data to identify trends, address issues, and recommend process improvements.
- Provide training, guidance, and ongoing education for new and existing team members on industry changes and standards.
Education
- Bachelor's Degree Healthcare Administration required or Bachelor's Degree Related Field of Study required
Can this role accept experience in lieu of a degree?
Yes
Experience
- Experience in healthcare claims review or processing 3-5 years required
- Experience in a senior or leadership role 1-2 years required
Knowledge, Skills and Abilities
- Strong knowledge of healthcare claims processes, coding (CPT, ICD-10), and payer regulations.
- Excellent leadership, communication, and problem-solving skills.
- Proficiency in claims processing software and healthcare management systems.
- Strong attention to detail and the ability to manage multiple tasks and priorities.
Physical Requirements
- Standing Occasionally (3-33%)
- Walking Occasionally (3-33%)
- Sitting Constantly (67-100%)
- Lifting Occasionally (3-33%)
- Carrying Occasionally (3-33%)
- Pushing Rarely (Less than 2%)
- Pulling Rarely (Less than 2%)
- Climbing Rarely (Less than 2%)
- Balancing Occasionally (3-33%)
- Stooping Occasionally (3-33%)
- Kneeling Rarely (Less than 2%)
- Crouching Rarely (Less than 2%)
- Crawling Rarely (Less than 2%)
- Reaching Occasionally (3-33%)
- Gross Manipulation (Handling) Constantly (67-100%)
- Fine Manipulation (Fingering) Frequently (34-66%)
- Feeling Constantly (67-100%)
- Foot Use Rarely (Less than 2%)
- Vision - Far Constantly (67-100%)
- Vision - Near Constantly (67-100%)
- Talking Constantly (67-100%)
- Hearing Constantly (67-100%)
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.
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Mass General Brigham Health Plan
Feb 19, 2025