Supervisor, Medicaid Claims Reviewer

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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.

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

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.

• Supervise and manage a team of Claims Reviewers responsible for the accurate and timely review, adjudication, and resolution of healthcare claims.
• Provide day-to-day leadership, workload direction, coaching, and support to ensure departmental productivity, quality, and turnaround-time expectations are consistently achieved.
• Analyze claims inventory and operational data to identify trends, recurring issues, root causes, and opportunities to improve accuracy, efficiency, and overall operational performance.
• Review and resolve complex, escalated, or high-risk claims issues, including payment disputes, reimbursement concerns, authorization-related issues, and claims requiring additional research.
• Conduct or oversee claims audits and quality reviews to validate processing accuracy and identify opportunities for improvement.
• Support departmental initiatives, claims projects, reprocessing efforts, audits, regulatory requests, and other operational priorities as assigned.
• Validate claim payment calculations against applicable contracts, fee schedules, reimbursement methodologies, benefits, and other payment requirements.
• Monitor individual and team performance through established key performance indicators, quality results, productivity metrics, inventory levels, and aging trends.
• Conduct regular performance discussions, coaching sessions, and formal evaluations to support employee development, accountability, and professional growth.
• Ensure claims are reviewed and processed in accordance with applicable regulatory requirements, contractual provisions, reimbursement methodologies, payer policies, and organizational procedures.
• Identify potential underpayments, over payments, billing discrepancies, processing errors, and systemic adjudication issues and coordinate corrective action as appropriate.
• Partner with Claims Configuration, Reimbursement Strategy, Clinical Operations, Provider Relations, Appeals and Grievances, Compliance, Finance, and other internal stakeholders to resolve claims issues and implement sustainable solutions.
• Develop, implement, and reinforce departmental policies, procedures, workflows, and controls to promote consistent and compliant claims processing.
• Escalate identified system, configuration, reimbursement, policy, or…