New

Third Party Reviewer

Mass General Brigham (Enterprise Services)
remote work
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
May 05, 2026
Third Party Claims Reviewer MGB Revenue Cycle Operations, supporting Aetna, Cigna, United, Wellpoint, Non-Contracted Commercial Team is hiring! The Teammate is responsible for conducting thorough and accurate reviews of healthcare billing and claims documentation. -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 potentially 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. High School Diploma or Equivalent required Can this role accept experience in lieu of a degree? No Experience in medical billing, claims processing, or coding within a healthcare environment, with a strong focus on third-party payer guidelines and regulations. Related experience, 1-2 years highly preferred Skills for Success 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. Working Model Requirements Remote Work requires secure, stable, quiet, compliant work area and free of dependent care M-F Eastern Business Hours Required using only MGB compliant equipment 8:00-4:30 PM EST preferred or 8:30-5:00 EST. Mass General Brigham Incorporated 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.