• Analyze itemized hospital bills and claims data to identify billing errors, coding discrepancies, DRG misassignments, and other overpayment opportunities. • Work directly with claims administrators on behalf of ASO clients to secure claim adjustments, recoveries, and repricing. • Perform detailed audits of hospital and facility claims, including itemized bills, UB-04 claim forms, medical records, and remittance advices, to validate billing accuracy. • Analyze DRG assignments and coding to identify DRG upcoding, unbundling, duplicate billing, and other irregularities that affect reimbursement. • Review high-cost and catastrophic claims (typically $100K+) to identify overpayments, contract misapplication, and opportunities for negotiated adjustments. • Evaluate claims against plan documents, provider contracts, reference-based pricing methodologies, and CMS guidelines to determine appropriate reimbursement. • Understand and apply stop loss (specific and aggregate) provisions, laser terms, and reporting requirements as they relate to claim adjustments and client financial exposure. • Serve as the subject matter expert and advocate on behalf of ASO clients in disputes with claims administrators (TPAs) and carriers regarding claim payment accuracy. • Prepare clear, well-documented findings packages (clinical, contractual, and coding rationale) to support requested claim adjustments and appeals.

Role Description The VA Claims Specialist is responsible for the filing of all VA expense claims and all non-conveyance claims, including Third Party claims, max guaranty claims, Compromise Sales, and Refunding claims in accordance with investor/insurer time frames and follow up on all claim payments. It is essential that these functions are handled as timely as possible within established requirements to minimize all associated losses. - File all VA Basic expense claims within insurer/investor timeframes - File all non-conveyance claims including third party claims, max guaranty claims, Compromise Sale claims and Refunding claims within investor/insurer timeframes. - Follow up daily/weekly on all outstanding claim proceeds - Work to resolve all exceptions on suspended claim funds or denied claims - Monitor daily reports and queues - Ensure Manager is kept informed of all trends and issues, including, but not limited to, VA claim curtailments and loss mitigation denials. Qualifications - Basic knowledge and experience with VA default guidelines and requirements - At least 3 years of experience filing VA Claims - Cloud Claims experience is a PLUS - Attention to detail with a high level of accuracy - Strong analytical and problem-solving skills - Excellent communication skills - Ability to meet deadlines in a fast-paced environment - Excellent organizational skills - Ability to work independently - Ability to read, analyze, and interpret documents such as legal documents, policies and procedures, and financial reports - Must be able to handle high volumes in a fast-paced environment - Ability to meet critical departmental and federal timelines with accuracy and efficiency Benefits - Medical Insurance - Dental Insurance - Vision Insurance - Life & Disability Insurances

Role Description Determine covered medical insurance benefits in accordance with the provisions of the plan document. Document medical claims processes by completing forms, reports, logs and records. Resolve medical claims by approving or denying, calculating benefit due and initiating payment or denial. Ensure legal compliance by following company policies, procedures, guidelines, as well as federal insurance regulations. - Account maintenance: Updating registration, authorization issues, identifying charge correction, processing adjustments as needed and denial follow up according to payer rules and departmental policies. - Use electronic billing system appropriately to follow up on outstanding denied claims and all no response claims. - Correct claims in electronic billing system for missing or invalid insurance or patient information according to procedures, and place account on hold if unable to resolve. - Follow up on denied or no response claims by calling third party payers or using payer websites. - Gather information from patients or other areas to resolve outstanding denied or no response claims. - Research accounts to take appropriate action necessary to resolve. - Keep management aware of issues and trends to enhance operations and escalate slow-pay issues to managerial level when necessary. - Use payer websites to stay current on payer rules and changes to include reading newsletters and communicating payer/claim issues and trends. - Maintain 95% quality standards on account follow and activity. - Maintain productivity standard as set forth by management team. - Other duties as assigned. Qualifications - Education: High School Degree or Equivalent - Work Experience: 0-6 months Benefits - Health, dental, vision, and life insurance - Employer Sponsored Retirement Plan - Paid time off and extended sick leave - Paid Parental Leave - Disability insurance plan options - Continuous professional and clinical training - Competitive pay - Annual Merit Increase - Wellbeing resources - Tuition Reimbursement - Employee perks and discounts - Employee referral program - Flexible schedule options - Certification incentive program

Role Description The DSNP Claims Resolution Coordinator is responsible for reviewing, researching, and resolving Dual Eligible Special Needs Plan (DSNP) claim inquiries, provider correspondence, and escalations received through Customer Service and internal business partners. This role determines whether claim adjustments are needed, applies Medicare and Medicaid benefit and payment guidelines, and ensures claims are processed accurately, timely, and in accordance with Mass General Brigham Health Plan policies, contractual requirements, and regulatory expectations. The coordinator uses independent judgment, strong analytical skills, and cross-functional collaboration to identify claim issues, support resolution, and help improve the member and provider experience. - Review, research, and resolve assigned DSNP claim inquiries, provider correspondence, and escalations using QNXT and other internal systems. - Determine appropriate claim action, including payment, denial, adjustment, manual entry, or pending for additional review, in accordance with applicable Medicare and Medicaid guidelines. - Validate benefits, authorizations, pricing, fee schedules, contracts, Letters of Agreement, and member eligibility to support accurate and timely claim resolution. - Maintain accurate documentation in applicable tracking systems, including call tracking records, claim notes, reports, and reimbursement request records. - Communicate and collaborate with Customer Service, Provider Relations, Configuration, Pricing, Compliance, and other business partners to resolve claim issues and escalations. - Identify, research, and escalate system, configuration, pricing, benefit, or process issues timely and with clear supporting detail. - Apply current desktop procedures, benefit documents, claims policies, and training resources to ensure consistent and compliant claim handling. - Meet established productivity, quality, timeliness, and attendance expectations while supporting member and provider satisfaction. - Support assigned reports, member reimbursement requests, special projects, and other departmental responsibilities as needed. - Model accountability, collaboration, inclusion, and a people-first approach in daily work and cross-functional interactions. - Other duties as required. Qualifications - Education: Associate’s degree preferred. - Experience: At least 2-3 years of healthcare claims experience required. - Knowledge of medical billing and coding principles, reimbursement methodologies, and insurance claim submission processes. - Knowledge of healthcare regulations and compliance requirements, including HIPAA guidelines. - Familiarity with Medicare, Medicaid, government programs, and applicable billing requirements. - Strong attention to detail and accuracy in claim submissions, research, documentation, and recordkeeping. - Excellent written and verbal communication skills to interact effectively with insurance companies, providers, members, patients, and colleagues. - Strong customer service orientation and ability to handle sensitive or difficult situations with empathy, professionalism, and sound judgment. Requirements - This is a remote role that can be done from most US states. - This is a full-time schedule (8-4:30 pm or 8:30-5:00 pm ET). - Remote workdays require a stable, secure, quiet, and compliant workspace. - Scheduled Weekly Hours: 40. - Employee Type: Regular. - Work Shift: Day (United States of America). - Pay Range: $19.81 - $28.30/Hourly. - Grade: 3. Benefits - Competitive salaries. - Flexible work options. - Career growth opportunities. - Comprehensive benefits package. - Recognition programs designed to celebrate contributions and support professional growth.