Medicare Advantage Claims Quality Control Reviewer
Partner's Healthcare

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

This role supports the quality control of claims entry and processing to identify claims processing errors and remediation prior to payment or denial.

Job Summary
Responsible for monitoring Quality Control (QC) of Claims Operations and the reporting of all metrics related to such activities.

Essential Functions
- Responsible for end-to-end pre-pay review of claims adjudicated in QNXT to ensure complete and accurate claims processing in alignment with Medicare regulations, including but not limited to accuracy for paper claim entry, application of benefits and cost-share, CCI/NCCI edits, authorizations, rate of payment, attributes, decision codes, and memos leading to identification of issues which require remediation prior to the weekly check run.
-Includes the post-pay review of Explanations of Payments to providers, as well as calculation and accumulation of MOOP, interest, sequestration, etc.
-Perform trend analysis and root cause review analysis.
-Responsible to ensure claims processing entry and adjudication accuracy
-Responsible for identifying potential areas of compliance vulnerability and risk and working with department supervisors/managers to develop and implement remediation plans and/or corrective action as needed and recommend appropriate solutions to enhance current quality assurance programs.
-Develop and implement new quality control processes, assist in the business testing process, and participate in projects.
-Completion of post-payment Claims Monthly Compliance Monitoring review which is delivered to senior leadership

Qualifications

Education

• Bachelor's Degree preferred

Experience

• At least 2-3 years of quality control experience within medical claims required
• At least 2-3 years of healthcare experience required
• At least 2-3 years of Medicare Advantage medical claims processing experience required
• At least 2-3 years of MassHealth (Medicaid) medical claims processing experience highly preferred
• AAPC certification(s) a plus

Knowledge, Skills and Abilities

• Experience in monitoring, measuring and reporting on quality and productivity of medical claims processing.
• Strong analytical abilities to assess risks, analyze data, and make informed recommendations for improvement.
• Excellent written and verbal communication skills to prepare reports, deliver training sessions and collaborate effectively with multifaceted teams across different specialties.
• Ability to understand claims processing edits, correct coding edits, medically unlikely edits

Additional Job Details (if applicable)

Working Conditions

• This is a remote role that can be done from most US states
• 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.
• This is a Monday through Friday role with a schedule of either 8:00 AM - 4:30 PM EDT or 8:30 AM - 5:00 PM EDT.

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range
$25.50 - $36.49/Hourly

Grade
5

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

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