Mass General Brigham connects a full spectrum of care across a system of academic medical centers, specialty and community hospitals, physician networks, a heal
Third Party Reviewer
Location
Massachusetts + 1 moreAll locations: Massachusetts | EST (UTC-5)
Posted
42 days ago
Salary
$20 - $28 / hour
Seniority
Mid Level
No structured requirement data.
Job Description
Third Party Reviewer
Mass General Brigham
Role Description 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. - 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. - 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. 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. Benefits - Competitive base pay. - Comprehensive benefits. - Career advancement opportunities. - Differentials, premiums, and bonuses as applicable. - Recognition programs designed to celebrate your contributions and support your professional growth.
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