Claims Resolutions Coordinator

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jun 30, 2025
This is a remote role that can be done from most US states The Claims Resolution Coordinator reviews all provider correspondence and inquiries from Customer Service then determines the need for claims adjustment. Processing provider correspondence efficiently while adhering to timelines and Mass General Brigham Health Plan guidelines utilizing independent decision-making skills as appropriate when adjusting claims. The ideal candidate has at least 3-5 years of experience in the health insurance industry in functions such as hospital or physician biller OR in the call center -Review and research assigned claims by navigating multiple systems and platforms and accurately capturing the data/information necessary for processing (e.g. verify pricing/Fee Schedules, contracts and Letters of Agreement, prior authorizations, applicable member benefits) -Adjust, or uphold disposition of claims as appropriate in a timely and accurate manner -Manually enters claims into QNXT as needed. -Ensure that the proper benefits are applied to each claim by using the appropriate processes and desktop procedures (e.g. claims processing policies and procedures, benefit plan documents/ certificates) -Create/update, work and close Call tracking records in QNXT call tracking module. -Adhere to all reporting requirements communicate and collaborate with other departments to resolve claims errors/issues, using clear, simple language to ensure understanding. -Learn and leverage new systems and training resources to help apply claims processes/procedures appropriately (e.g. on-line training classes, coaches/mentors) Meet the performance, goals established for the position in the areas of production, accuracy, quality, member and Provider satisfaction and attendance -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. -Process member reimbursement requests as needed Education Associate's degree in Healthcare Management preferred Licenses and Credentials Certified Professional Coding preferred Experience At least 2-3 years of healthcare billing experience required Previous claims processing or similar industry experience Knowledge, Skills, and Abilities Knowledge of medical billing and coding principles, reimbursement methodologies, and insurance claim submission processes. Knowledge of healthcare regulations and compliance, including HIPAA guidelines. Familiarity with insurance plans, government programs, and their billing requirements. Strong attention to detail and accuracy in claim submissions and recordkeeping. 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. Working Conditions This is a remote role that can be done from most US states This is a full-time Monday through Friday role, Eastern business hours are required Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.