Supervisor, Medicaid Claims Reviewer

Job description

Site: 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. Job Summary 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. The Supervisor, Medicaid Claims Review is responsible for leading a high-performing team focused on Medicaid claims quality, payment accuracy, and adjudication integrity. This role oversees daily inventory management while driving continuous improvement through denial trend analysis, high-dollar claim oversight, and proactive identification of adjudication risks. The Supervisor partners cross-functionally with Configuration, Reimbursement Strategy, Pharmacy Operations, and Payment Integrity to strengthen claims outcomes and reduce rework across the enterprise. Responsible for overseeing a team that assesses Medicaid claims for accuracy, compliance, and eligibility, ensuring that claims are processed efficiently and in accordance with industry standards, regulatory requirements, and organizational policies. This position will guide and support the claims review team, handle escalations, and collaborate with other departments to improve claims processing and ensure timely reimbursements. Essential Functions • 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, overpayments, 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 operational issues and support remediation through appropriate business and technical channels. • Provide training, guidance, and ongoing education to new and existing staff regarding claims processing requirements, regulatory changes, reimbursement rules, departmental procedures, and system updates. • Maintain awareness of changes to healthcare regulations, payer requirements, reimbursement methodologies, billing guidelines, and industry standards that may impact claims operations. • Promote a culture of accountability, collaboration, continuous improvement, and exceptional service to members and providers. • Perform other duties as assigned Qualifications Education Bachelor's degree required (experience can be considered in lieu of degree) License Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or comparable healthcare claims/coding certification preferred. Experience At least 3-5 years of experience in healthcare claims review or processing required At least 1-2 years of experience in a senior or leadership role required Experience working within a health plan, managed care organization, third-party administrator, or similar payer environment strongly preferred. Experience resolving complex claims, reimbursement, coding, authorization, or payment-related issues preferred. Experience monitoring operational performance, including claims inventory, turnaround time, productivity, and quality metrics preferred Knowledge, Skills, and Abilities Strong knowledge of healthcare claims adjudication, reimbursement, and payment methodologies. Working knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), ICD-10-CM/PCS, revenue codes, modifiers, and other healthcare coding standards. Knowledge of Medicaid and other applicable payer requirements and regulatory standards. Ability to interpret provider contracts, reimbursement provisions, fee schedules, payment policies, and claims-processing guidelines. Strong leadership and people-management skills, including coaching, performance management, employee development, and workload prioritization. Strong analytical and problem-solving skills with the ability to identify trends, perform root-cause analysis, and develop sustainable operational solutions. Ability to analyze claims data and operational metrics and translate findings into actionable recommendations. Excellent written and verbal communication skills with the ability to communicate complex claims issues clearly to both technical and non-technical stakeholders. Demonstrated ability to collaborate effectively across operational, clinical, technical, financial, and compliance functions. Strong organizational skills with the ability to manage competing priorities, escalations, deadlines, and changing business needs. High degree of accuracy, attention to detail, sound judgment, and accountability. Proficiency with healthcare claims-processing systems, workflow applications, Microsoft Office applications, and reporting or analytical tools. Ability to learn and adapt to evolving healthcare regulations, reimbursement methodologies, technologies, policies, and operational processes. Additional Job Details (if applicable) Working Conditions This is a full-time role with a Monday through Friday schedule, generally 8:30-5:00 PM Eastern Time This position is eligible for remote work from approved U.S. locations, subject to organizational requirements. Remote employees must maintain a stable internet connection and a secure, private, quiet workspace appropriate for handling confidential and protected health information. Remote workspace requirements, including privacy and security standards, may be verified in accordance with organizational policy Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $79,560.00 - $115,720.80/Annual Grade 7 At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. 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 your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.