Third Party Reviewer

About the Role

Responsible for conducting thorough and accurate reviews of healthcare billing and claims documentation.

Responsibilities

• 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.

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 preferred).

Skills

• 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.

Schedule

• Monday to Friday, Eastern Business hours (shifts will range between 6 AM to 6 PM EST).
• Scheduled weekly hours: 40.
• Remote work with a quiet, secure, stable, HIPAA-compliant workstation required.

Pay

Pay range: $19.81 - $28.30/hourly (Grade 3). At Mass General Brigham, base pay is determined by skills, relevant experience, education, certifications, and other essential factors. The provided range is based on minimum job qualifications.

Benefits

In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses (as applicable), and recognition programs designed to celebrate contributions and support professional growth.