Medicare Advantage Claims Quality Control Reviewer

Mass General Brigham • Somerville, MA

1d • $26 - $36 • Remote

About The Position

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.

Requirements

• Bachelor's Degree preferred
• 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
• 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

Nice To Haves

• At least 2-3 years of MassHealth (Medicaid) medical claims processing experience highly preferred
• AAPC certification(s) a plus

Responsibilities

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level