New

Claims Review Specialist, DSNP

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Apr 02, 2026
The DSNP Claims Review Specialist reviews and processes Senior Care Options (SCO) and One Care medical claims requiring manual intervention when autoadjudication is not achieved. The Specialist ensures claims are adjudicated accurately, timely, and in compliance with Mass General Brigham Health Plan administrative policies, operational procedures, and clinical guidelines. The ideal candidate brings handson experience with SCO and One Care claims processing and demonstrated proficiency in QNXT or similar claims adjudication systems (e.g., Facets). Principal Duties and Responsibilities: * Adjudicate claims to pay, deny, or pend as appropriate in a timely and accurate manner according to company policy and desktop procedure. * Review and research assigned claims by navigating multiple systems and platforms, then accurately capturing the data/information necessary for processing (e.g., verify pricing/fee schedules, contracts, Letter of Agreement, prior authorization, applicable member benefits). * Manually enters claims into claims processing system as needed. * Ensure that the proper benefits are applied to each claim by using the appropriate processes and desktop procedures (e.g., claims processing policies, procedures, benefits plan documents). * Communicate and collaborate with external department to resolve claims errors/issues, using clear and concise language to ensure understanding. * Learn and leverage new systems and training resources to help apply claims processes/procedures appropriately (e.g., online training classes, coaches/mentors). * Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction. * Create/update work within the call tracking record keeping system. * Adhere to all reporting requirements. * Keep up to date with Desktop Procedures and effectively apply this knowledge in the processing of claims and in providing customer service. * Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner. * Process member reimbursement requests as needed. Education High School Diploma required and Associate's Degree Healthcare Management preferred Experience Related Healthcare Experience 1-2 years required At least 2-3 years of previous experience in the health insurance industry in functions such as hospital or physician biller, call center experience, claims processing, or similar industry experience highly preferred. SCO and OneCare claims processing experience highly preferred Knowledge, Skills, and Abilities Knowledge of healthcare claims processes for (D-SNP/fully-integrated Medicare & Medicaid/Mass Health highly preferred. Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes highly preferred Knowledge of medical terminology highly preferred. Familiarity with insurance plans, government programs, and their billing requirement preferred. Knowledge of claim forms (professional and facility) highly preferred Professional Coder Certificate is highly desirable Strong customer service orientation and ability to handle sensitive or difficult situations with empathy and professionalism. Working Conditions This is a remote role that can be done This is a full-time schedule (8-4:30 pm or 8:30-5:00 pm ET) 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.