Claims Review Specialist, DSNP
Posted 2026-05-06
Remote, USA
Full-time
Immediate Start
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.
Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.
We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.
Job Summary
The D‑SNP Claims Review Specialist reviews and processes Senior Care Options (SCO) and One Care medical claims requiring manual intervention when auto‑adjudication is not achieved. The Specialist ensures claims are adjudicated accurately, timely, and in compliance with Mass General Brigham Health Plan administrative policies, operational procedures, and clinical guidelines. The ideal candidate brings hands‑on experience with SCO and One Care claims processing and demonstrated proficiency in QNXT or similar claims adjudication systems (e.g., Facets).Principal Duties and Responsibilities:
• Adjudicate claims to pay, deny, or pend as appropriate in a timely and accurate manner according to company policy and desktop procedure.
• Review and research assigned claims by navigating multiple systems and platforms, then accurately capturing the data/information necessary for processing (e.g., verify pricing/fee schedules, contracts, Letter of Agreement, prior authorization, applicable member benefits).
• Manually enters claims into claims processing system 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, procedures, benefits plan documents).
• Communicate and collaborate with external department to resolve claims errors/issues, using clear and concise language to ensure understanding.
• Learn and leverage new systems and training resources to help apply claims processes/procedures appropriately (e.g., online training classes, coaches/mentors).
• Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction.
• Create/update work within the call tracking record keeping system.
• Adhere to all reporting requirements.
• 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.
Qualifications
Education
- High School Diploma required and Associate's Degree Healthcare Management preferred
Experience
- Related Healthcare Experience 1-2 years required
- At least 2-3 years of previous experience in the health insurance industry in functions such as hospital or physician biller, call center experience, claims processing, or similar industry experience highly preferred.
- SCO and OneCare claims processing experience highly preferred
Knowledge, Skills, and Abilities
- Knowledge of healthcare claims processes for (D-SNP/fully-integrated Medicare & Medicaid/Mass Health highly preferred.
- Knowledge of ICD-10, HCPCS, CPT-4, and Revenue Codes highly preferred
- Knowledge of medical terminology highly preferred.
- Familiarity with insurance plans, government programs, and their billing requirement preferred.
- Knowledge of claim forms (professional and facility) highly preferred
- Professional Coder Certificate is highly desirable
- Strong customer service orientation and ability to handle sensitive or difficult situations with empathy and professionalism.
Additional Job Details (if applicable)
Working Conditions
- This is a remote role that can be done
- This is a full-time schedule (8-4:30 pm or 8:30-5:00 pm ET)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$17.71 - $25.28/Hourly
Grade
2
EEO Statement:
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.