Third Party Reviewer
Mass General Brigham
Summary
Responsible for conducting thorough and accurate reviews of healthcare billing and claims documentation.
Job description
Job Summary
Responsible for conducting thorough and accurate reviews of healthcare billing and claims documentation.
Essential Functions
- 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 potential 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.
Additional Job Details
- Monday through Friday Eastern business hours are required for this remote position. Following training, scheduled shifts will fall between 6:00 AM and 6:00 PM EST. The training schedule will be conducted Monday through Friday between 8:00 AM and 6:00 PM EST.
- A quiet, secure, and reliable HIPAA-compliant workspace is required to perform this role effectively.
Requirements
- 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
- 1-2 years experience 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
Benefits
- Career Advancement Opportunities
- Differentials
- Premiums
- Bonuses
- Recognition Programs
Company overview
Mass General Brigham is one of the largest integrated healthcare delivery systems in the United States, formed through the merger of Massachusetts General Hospital and Brigham and Women's Hospital. Based in Boston, Massachusetts, this academic medical center system operates multiple hospitals, specialty facilities, and community health centers throughout New England. The organization is renowned for its world-class patient care, cutting-edge medical research, and comprehensive medical education programs. As a teaching affiliate of Harvard Medical School, Mass General Brigham trains the next generation of healthcare professionals while advancing medical science through groundbreaking research initiatives. The system provides a full continuum of healthcare services, from primary care and preventive medicine to complex specialty treatments and emergency services. With a focus on innovation and patient-centered care, Mass General Brigham consistently ranks among the top hospital systems in the nation for clinical excellence and research output.