Supervisor, Medicaid Claims Reviewer

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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 is supervising a team of roughly 5 Medicaid Claims Reviewers. The role is claims inventory management, identifying ACO claims adjudication errors, doing high-dollar reviews, noting claims denial trends, coaching/mentoring team members, and participating in the development of departmental desktop procedures.
The ideal candidate has a strong background in Medicaid/ACO claims processing and is a Certified Coder who can understand the difference in different claims edits.
** Job Summary
** 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  
-Performs other duties as assigned  
-Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records.
-Analyze claim payment amounts and compare them to contracted rates, fee schedules, and industry benchmarks.
-Identify underpayments, over payments, and potential billing errors.
-Conduct comprehensive audits of medical claims to verify compliance with billing regulations, payer policies, and internal policies and procedures.
-Stay updated on insurance company policies, billing guidelines, and reimbursement rules.
** Qualifications
* *** Education
* ** Bachelor's degree required (experience can be considered in lieu of degree)
** License
* ** Certified Professional Coder (CPC) preferred
** Experience
* ** At least 3-5 years of experience in healthcare claims review or processing required
* At least 1-2 years of experience in a senior or leadership role 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
** Additional Job Details (if applicable)
**** Working Conditions
*** This is a full-time role with a Monday through Friday, 8:30-5 schedule
* This is a remote role that can be done from most US states
** Remote Type
** Remote
* * Work Location
** 399 Revolution Drive
** Scheduled Weekly Hours
** 40
* * Employee Type
** Regular
* * Work Shift
** Day (United States of America)
** Pay Range**$78,000.00 - $/Annual
** Grade
* * 7

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…