Supervisor, Medicaid Claims Reviewer

Overview

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.

• 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
• Perform other duties as assigned
• Ensure that 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

• Bachelor's degree required (experience can be considered in lieu of degree)

• Certified Professional Coder (CPC) preferred

• 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

• 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

• 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

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.