<p>Site: Mass General Brigham Health Plan Holding Company, Inc.</p> <p>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.</p> <p>This is a hybrid role that requires an onsite presences at the office 1x/month.</p> <p>Job Summary</p> <p>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.</p> <p>Qualifications</p> <p>Essential Functions</p> <ul> <li>Supervise and manage a team of claims reviewers to ensure accurate and timely healthcare claims processing. </li><li>Oversee claims review and analysis to ensure compliance with healthcare regulations, payer requirements, and organizational policies. </li><li>Resolve escalated or complex claims issues, ensuring appropriate adjudication and dispute resolution. </li><li>Monitor team performance, provide feedback, and conduct regular evaluations to support professional growth. </li><li>Implement and enforce policies and procedures to streamline the claims review process for greater accuracy and efficiency. </li><li>Collaborate with billing, coding, and compliance teams to ensure adherence to regulatory and payer standards. </li><li>Analyze claims data to identify trends, address issues, and recommend process improvements. </li><li>Provide training, guidance, and ongoing education for new and existing team members on industry changes and standards. </li></ul> <p>Additional Job Details (if applicable)</p> <p>Education</p> <ul> <li>Bachelor's Degree Healthcare Administration required or Bachelor's Degree Related Field of Study required </li></ul> <p>Can this role accept experience in lieu of a degree?</p> <p>Yes</p> <p>Experience</p> <ul> <li>Experience in healthcare claims review or processing 3-5 years required </li><li>Experience in a senior or leadership role 1-2 years required </li></ul> <p>Knowledge, Skills and Abilities</p> <ul> <li>Strong knowledge of healthcare claims processes, coding (CPT, ICD-10), and payer regulations. </li><li>Excellent leadership, communication, and problem-solving skills. </li><li>Proficiency in claims processing software and healthcare management systems. </li><li>Strong attention to detail and the ability to manage multiple tasks and priorities. </li></ul> <p>Physical Requirements</p> <ul> <li>Standing Occasionally (3-33%) </li><li>Walking Occasionally (3-33%) </li><li>Sitting Constantly (67-100%) </li><li>Lifting Occasionally (3-33%) </li><li>Carrying Occasionally (3-33%) </li><li>Pushing Rarely (Less than 2%) </li><li>Pulling Rarely (Less than 2%) </li><li>Climbing Rarely (Less than 2%) </li><li>Balancing Occasionally (3-33%) </li><li>Stooping Occasionally (3-33%) </li><li>Kneeling Rarely (Less than 2%) </li><li>Crouching Rarely (Less than 2%) </li><li>Crawling Rarely (Less than 2%) </li><li>Reaching Occasionally (3-33%) </li><li>Gross Manipulation (Handling) Constantly (67-100%) </li><li>Fine Manipulation (Fingering) Frequently (34-66%) </li><li>Feeling Constantly (67-100%) </li><li>Foot Use Rarely (Less than 2%) </li><li>Vision - Far Constantly (67-100%) </li><li>Vision - Near Constantly (67-100%) </li><li>Talking Constantly (67-100%) </li><li>Hearing Constantly (67-100%) </li></ul> <p>Remote Type</p> <p>Hybrid</p> <p>Work Location</p> <p>399 Revolution Drive</p> <p>Scheduled Weekly Hours</p> <p>40</p> <p>Employee Type</p> <p>Regular</p> <p>Work Shift</p> <p>Day (United States of America)</p> <p>EEO Statement:</p> <p>Mass General Brigham Health Plan Holding Company, Inc. 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.</p> <p>Mass General Brigham Competency Framework</p> <p>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.</p>