Third Party Reviewer

Site: Mass General Brigham Incorporated

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.

Job Summary

Third Party Claims Reviewer

MGB Revenue Cycle Operations, supporting Aetna, Cigna, United, Wellpoint, Non-Contracted Commercial Team is hiring!

The Teammate is responsible for conducting thorough and accurate reviews of healthcare billing and claims documentation.

• Review medical claims and billing documentation to ensure accuracy, completeness, and compliance with regulatory requirements, coding guidelines, and payer policies.
• Verify the appropriateness of billed services, procedures, and diagnosis codes.
• Identify potential compliance issues, including incorrect coding, unbundling, upcoding, and other billing irregularities.
• Conduct audits to ensure adherence to industry regulations, such as HIPAA and CMS guidelines.
• Evaluate the accuracy and adequacy of clinical documentation, ensuring it supports the billed services and complies with medical necessity guidelines.
• Collaborate with healthcare providers to obtain additional information or clarification, if necessary.
• Analyze claim denials and rejections, identify root causes, and recommend corrective actions to prevent future denials.
• Work closely with billing and coding teams to resolve claim discrepancies and resubmit claims, if needed.
• Identify potentially fraudulent activities or abuse in billing practices.
• Report suspicious activities and work with internal compliance teams and external agencies to investigate and resolve fraud cases.
  
  

Qualifications

• High School Diploma or Equivalent required
• Can this role accept experience in lieu of a degree? No
• Experience in medical billing, claims processing, or coding within a healthcare environment, with a strong focus on third-party payer guidelines and regulations.
• Related experience, 1-2 years highly preferred
  
  

Skills for Success

• In-depth knowledge of coding systems (e.g., ICD-10-CM, CPT, HCPCS) and billing requirements across various healthcare settings.
• Familiarity with billing and coding compliance regulations, such as HIPAA, CMS guidelines, and National Correct Coding Initiative (NCCI) edits.
• Strong analytical skills and attention to detail, with the ability to review and interpret complex billing and coding documentation.
• Proficiency in using billing software and electronic health record (EHR) systems.
• Excellent communication and interpersonal skills, with the ability to collaborate effectively with internal teams, healthcare providers, and insurance companies.
  
  

Additional Job Details (if Applicable)

Working Model Requirements

• Remote Work requires secure, stable, quiet, compliant work area and free of dependent care
• M-F Eastern Business Hours Required using only MGB compliant equipment
• 8:00–4:30 PM EST preferred or 8:30-5:00 EST.
  
  

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$19.81 - $28.30/Hourly

Grade

3

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

0100 Mass General Brigham Incorporated 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.