Mass General Brigham · 22 hours ago
ACO Medicaid Claims Review Specialist
United States
Full-time
Remote
Entry, Mid Level
$17.36/hr - $24.79/hr
1+ years expMass General Brigham is a leading integrated healthcare system dedicated to providing exceptional care. The ACO Medicaid Claims Review Specialist will review and adjudicate claims to ensure accurate coding, compliance with billing regulations, and resolve claims errors, all while contributing to an exceptional member experience.
Health CareHome Health CareMedical
Responsibilities
Review claims to ensure accurate coding, appropriate documentation, and compliance with applicable billing regulations and payer guidelines
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, prior authorization, applicable member benefits)
Communicate and collaborate with external departments to resolve claims errors/issues, using clear and concise language to ensure understanding
Review and adjudicate medical claims submitted by healthcare providers, insurance companies, and patients to identify discrepancies, errors, or potential fraud
Analyze and validate the assigned diagnosis codes (ICD-10) and procedure codes (CPT) on medical claims to ensure accurate representation of services rendered and compliance with coding standards
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
Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records
Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction
Qualification
Required
High School Diploma or Equivalent required
At least 1-2 years of healthcare billing experience required
Knowledge of Medicaid/ACO claims processing
Knowledge of claim types including professional, facility, DME, outpatient, and inpatient
Ability to prioritize and manage aged claims (e.g., 30+ day inventory) to meet program guidelines and turnaround requirements
Strong attention to detail and accuracy in claim review, submissions, and documentation
Excellent communication skills, both written and verbal, to interact effectively with insurance companies, patients, and colleagues
Strong customer service orientation and ability to handle sensitive or difficult situations with empathy and professionalism
Preferred
Associate's Degree preferred
Professional Coder (CPC) license preferred
At least 2–4 years of experience in healthcare claims processing, billing, or the health insurance industry (e.g., hospital or physician billing) highly preferred
Experience with core healthcare claims processing and billing system highly preferred
Strong working knowledge of managed care concepts and medical coding, including ICD-10, CPT, HCPCS, and Revenue Codes highly preferred
Benefits
Competitive salaries
Benefits package with flexible work options
Career growth opportunities
Comprehensive benefits
Differentials
Premiums and bonuses
Company
Mass General Brigham
Mass General Brigham specializes in providing medical treatments and health diagnostics services.
10001+ employees
H1B Sponsorship
Mass General Brigham has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (77)
2024 (61)
2023 (93)
2022 (70)
2021 (80)
2020 (29)
Funding
Current Stage
Late StageLeadership Team
E
Erin Flanigan
SVP, Human Resources, Community, Specialty Hospital Division
O’Neil A. Britton
Chief Integration Officer, Executive Vice President
Recent News
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