This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Authorization Denial Appeal Specialist is responsible for managing and appealing denied prior authorizations for orthotic and prosthetic (O&P) devices across U.S ForMotion Clinics. This role partners closely with patients, clinicians, prescribing physicians, and payers to obtain required documentation, prepare comprehensive appeal submissions, and guide cases through payer review processes. - Manage end to end appeal workflows for denied prior authorizations related to orthotic and prosthetic devices. - Collaborate with patients, clinicians, and prescribing physicians to obtain medical records, clinical notes, letters of medical necessity, and other supporting documentation required for appeals. - Obtain, track, and maintain signed Appointment of Representative (AOR) forms from patients to enable payer communication. - Research payer manuals, coverage guidelines, medical policies, and provider portals to identify denial rationale and appeal requirements. - Develop customized, case by case appeal strategies based on clinical justification, payer policy, and documentation standards. - Draft clear, comprehensive, and payer specific appeal letters supporting medical necessity and policy alignment. - Compile and submit complete appeal packages through payer portals, fax, mail, or other required submission channels. - Monitor appeal status through payer systems and follow up as needed to ensure timely review and resolution. - Coordinate and participate in Peer to Peer (P2P) reviews when required, including preparation of supporting materials and scheduling with clinicians or prescribing physicians. - Proactively communicate appeal status, updates, approvals, and denials to both the patient and the clinic throughout the review process. - Track appeal deadlines, determinations, and outcomes to ensure compliance with payer timelines. - Maintain accurate, compliant documentation in EMR systems and internal tracking tools. - Provide non-managerial guidance and subject matter support to peers regarding authorization and appeal processes. - Ensure strict adherence to HIPAA and other legal and ethical standards in the handling of protected health information. Qualifications - Bachelor’s degree in business, healthcare, or related field or equivalent combination of education and experience required. - 2+ years of experience in the O&P industry utilizing EMR systems. - Prior experience and working knowledge of Commercial, Medicare, & Medicaid Insurances including authorizations, appeals/denials. - Proficient with Microsoft Office, Opie/Nymbl EMRs, ICD10 coding, medical terminology. Requirements - Ethical Conduct - Computer Proficiency - Demonstrates excellent people skills with the ability to interface with patients, physicians, and coworkers in a tactful, informed and service-oriented manner. - Detailed oriented. - Experience coordinating and participating in Peer to Peer (P2P) reviews. - Familiarity with Medicare, Medicaid, and commercial payer policies as they relate to O&P services. - Ability to interpret complex payer policy language and apply it to clinical scenarios. - Strong analytical, problem solving, and critical thinking skills. - Professional, patient centered communication style. - Ability to balance patient advocacy with payer compliance and regulatory requirements. Benefits - A culture rooted in trust, empathy, and Nordic-inspired flat hierarchies. - Tailored onboarding and a buddy system to help you feel at home from day one. - Continuous learning through e-learning, training, and language courses. - A “you” culture where everyone—from interns to executives—is treated with respect. - Competitive Compensation Packages. - Medical, Dental, and Vision Benefits. - 401(k) Retirement Plan with employer matching contribution. - 9 paid holidays. - 13 vacation days, birthday and two (2) volunteer days. - 8 sick days within your first year of employment. - Paid Parental Bonding. - The US hourly range for this full-time position is $29.38 - $31.25/hr + bonus + benefits.

Site: Mass General Brigham Health Plan Holding Company, Inc. 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. The Supervisor, Commercial Claims Review is responsible for leading a high-performing team focused on Commercial claims quality, payment accuracy, and adjudication integrity. This role oversees daily inventory management while driving continuous improvement through denial trend analysis, high-dollar claim oversight, and proactive identification of adjudication risks. The Supervisor partners cross-functionally with Configuration, Reimbursement Strategy, Pharmacy Operations, and Payment Integrity to strengthen claims outcomes and reduce rework across the enterprise. Job Summary 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. Essential Functions -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 -Performs other duties as assigned -Ensure that the 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, overpayments, 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. Qualifications Education - Bachelor's degree required (experience can be considered in lieu of degree) License - Certified Professional Coder (CPC) preferred - Pharmacy Tech License preferred Experience - 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 Knowledge, Skills, and Abilities - 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 Additional Job Details (if applicable) Working Conditions - 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 Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $79,560.00 - $115,720.80/Annual Grade 7 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: 8925 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. 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.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description This role involves analyzing mid- and higher-level general liability claims to determine benefits due and ensure ongoing adjudication of claims within company standards and industry best practices. - Manages mid-level general liability claims by gathering information to determine liability exposure - Assigns reserve values to claims, making claims payments as necessary, and settling claims up to designated authority level - Assesses liability and resolves claims within evaluation - Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract - Manages subrogation of claims and negotiates settlements - Communicates claim action with claimant and client - Ensures claim files are properly documented and claims coding is correct - May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review - Maintains professional client relationships Qualifications - Bachelor's degree from an accredited college or university preferred - Four (4) years of claims management experience or equivalent combination of education and experience required - Subject matter expert of appropriate insurance principles and laws for line-of-business handled - Excellent oral and written communication, including presentation skills - PC literate, including Microsoft Office products - Analytical and interpretive skills - Strong organizational skills - Good interpersonal skills - Excellent negotiation skills - Ability to work in a team environment - Ability to meet or exceed Service Expectations Requirements - Clear and conceptual thinking ability - Excellent judgment, troubleshooting, problem solving, analysis, and discretion - Ability to handle work-related stress - Ability to handle multiple priorities simultaneously - Ability to meet deadlines - Computer keyboarding, travel as required - Hearing, vision and talking Benefits - Comprehensive benefits package including medical, dental, vision - 401k and matching - PTO - Disability and life insurance - Employee assistance - Flexible spending or health savings account - Other additional voluntary benefits

• Support team discussions, aid in team claims issue resolution efficiently, and lead by example. • Accurately review, investigate, and verify coverage to ensure proper processing of medical claims, identifying key processing requirements based on Summary Plan Descriptions (SPD), policies, and departmental procedures • Foster a collaborative team culture through open, honest communication. • Assist with training new team members and support ongoing development through continuous education and skills training. • Support in helping develop team members to perform at their highest level by offering coaching and sharing expertise/best practices. • Review claims queues and provide expertise to address nuances with appropriate parties. • Continually meet department metrics and quality set forth by leadership Provide ongoing feedback to improve departmental workflows and procedures. • Communicate complex claims issues clearly through documentation and direct communications. • Process complex claim scenarios in accordance with Summary Plan Descriptions (SPDs). Areas of expertise include, but are not limited to: Coordination of Benefits (COB), Prior Authorization, Claim Adjustments, Health Reimbursement Arrangements (HRA), Transplant Claims, and High Dollar Claims Processing. • Provide feedback to leadership on system enhancements or training gaps.