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DSNP Claims Quality Control Reviewer

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Nov 03, 2025
Responsible for monitoring Quality Control (QC) of Claims Operations and the reporting of all metrics related to such activities. Essential Functions - Responsible for end-to-end pre-pay review of claims adjudicated in QNXT to ensure complete and accurate claims processing in alignment with Medicare and MassHealth (Medicaid) regulations, including but not limited to accuracy for paper claim entry, application of benefits, CCI/NCCI edits, authorizations, rate of payment, attributes, decision codes, and memos leading to identification of issues which require remediation prior to the weekly check run. -Includes the post-pay review of Explanations of Payments to providers, as well as calculation and accumulation of MOOP, interest, sequestration, etc. -Perform trend analysis and root cause review analysis. -Responsible to ensure claims processing entry and adjudication accuracy -Responsible for identifying potential areas of compliance vulnerability and risk and working with department supervisors/managers to develop and implement remediation plans and/or corrective action as needed and recommend appropriate solutions to enhance current quality assurance programs. -Develop and implement new quality control processes, assist in the business testing process, and participate in projects. -Completion of monthly post-payment Compliance monitoring review. Education Bachelor's Degree Related Field of Study required (experience can be substituted in lieu of degree) Experience At least 2-3 years of quality control experience within medical claims required At least 2-3 years of healthcare experience required At least 2-3 years of Medicare and MassHealth (Medicaid) medical claims processing experience highly preferred Prior Duals/DSNP/Senior Care Options or One Care claims experience preferred. Knowledge, Skills and Abilities Experience in monitoring, measuring and reporting on quality and productivity of medical claims processing. Strong analytical abilities to assess risks, analyze data, and make informed recommendations for improvement. Excellent written and verbal communication skills to prepare reports, deliver training sessions and collaborate effectively with multifaceted teams across different specialties. Working Conditions This is a remote role that can be done from most US states Employees must use a stable, secure, and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment. This is a Monday through Friday role with a schedule of either 8:00 AM - 4:30 PM EDT or 8:30 AM - 5:00 PM EDT. Mass General Brigham Health Plan Holding Company, Inc. 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.