DSNP Claims Resolution Coordinator
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AI Summary
The coordinator is responsible for researching and resolving DSNP claim inquiries, provider correspondence, and escalations. This includes determining claim adjustments and ensuring processing aligns with Medicare, Medicaid, and organizational policies.
Site: Mass General Brigham Health Plan Holding Company, Inc.
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 DSNP Claims Resolution Coordinator is responsible for reviewing, researching, and resolving Dual Eligible Special Needs Plan (DSNP) claim inquiries, provider correspondence, and escalations received through Customer Service and internal business partners. This role determines whether claim adjustments are needed, applies Medicare and Medicaid benefit and payment guidelines, and ensures claims are processed accurately, timely, and in accordance with Mass General Brigham Health Plan policies, contractual requirements, and regulatory expectations. The coordinator uses independent judgment, strong analytical skills, and cross-functional collaboration to identify claim issues, support resolution, and help improve the member and provider experience.
Primary Responsibilities:
-Review, research, and resolve assigned DSNP claim inquiries, provider correspondence, and escalations using QNXT and other internal systems.
-Determine appropriate claim action, including payment, denial, adjustment, manual entry, or pending for additional review, in accordance with applicable Medicare and Medicaid guidelines.
-Validate benefits, authorizations, pricing, fee schedules, contracts, Letters of Agreement, and member eligibility to support accurate and timely claim resolution.
-Maintain accurate documentation in applicable tracking systems, including call tracking records, claim notes, reports, and reimbursement request records.
-Communicate and collaborate with Customer Service, Provider Relations, Configuration, Pricing, Compliance, and other business partners to resolve claim issues and escalations.
-Identify, research, and escalate system, configuration, pricing, benefit, or process issues timely and with clear supporting detail.
-Apply current desktop procedures, benefit documents, claims policies, and training resources to ensure consistent and compliant claim handling.
-Meet established productivity, quality, timeliness, and attendance expectations while supporting member and provider satisfaction.
-Support assigned reports, member reimbursement requests, special projects, and other departmental responsibilities as needed.
-Model accountability, collaboration, inclusion, and a people-first approach in daily work and cross-functional interactions.
-Other duties as required.Remote399 Revolution Drive40RegularDay (United States of America)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 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 DSNP Claims Resolution Coordinator is responsible for reviewing, researching, and resolving Dual Eligible Special Needs Plan (DSNP) claim inquiries, provider correspondence, and escalations received through Customer Service and internal business partners. This role determines whether claim adjustments are needed, applies Medicare and Medicaid benefit and payment guidelines, and ensures claims are processed accurately, timely, and in accordance with Mass General Brigham Health Plan policies, contractual requirements, and regulatory expectations. The coordinator uses independent judgment, strong analytical skills, and cross-functional collaboration to identify claim issues, support resolution, and help improve the member and provider experience.
Primary Responsibilities:
-Review, research, and resolve assigned DSNP claim inquiries, provider correspondence, and escalations using QNXT and other internal systems.
-Determine appropriate claim action, including payment, denial, adjustment, manual entry, or pending for additional review, in accordance with applicable Medicare and Medicaid guidelines.
-Validate benefits, authorizations, pricing, fee schedules, contracts, Letters of Agreement, and member eligibility to support accurate and timely claim resolution.
-Maintain accurate documentation in applicable tracking systems, including call tracking records, claim notes, reports, and reimbursement request records.
-Communicate and collaborate with Customer Service, Provider Relations, Configuration, Pricing, Compliance, and other business partners to resolve claim issues and escalations.
-Identify, research, and escalate system, configuration, pricing, benefit, or process issues timely and with clear supporting detail.
-Apply current desktop procedures, benefit documents, claims policies, and training resources to ensure consistent and compliant claim handling.
-Meet established productivity, quality, timeliness, and attendance expectations while supporting member and provider satisfaction.
-Support assigned reports, member reimbursement requests, special projects, and other departmental responsibilities as needed.
-Model accountability, collaboration, inclusion, and a people-first approach in daily work and cross-functional interactions.
-Other duties as required.
Qualifications
Education:
- Associate’s degree preferred.
Experience:
- At least 2-3 years of healthcare claims experience required
Knowledge, Skills, and Abilities:
- Knowledge of medical billing and coding principles, reimbursement methodologies, and insurance claim submission processes.
- Knowledge of healthcare regulations and compliance requirements, including HIPAA guidelines.
- Familiarity with Medicare, Medicaid, government programs, and applicable billing requirements.
- Strong attention to detail and accuracy in claim submissions, research, documentation, and recordkeeping.
- Excellent written and verbal communication skills to interact effectively with insurance companies, providers, members, patients, and colleagues.
- Strong customer service orientation and ability to handle sensitive or difficult situations with empathy, professionalism, and sound judgment.
Additional Job Details (if applicable)
Working Conditions
- This is a remote role that can be done from most US states
- This is a full-time schedule (8-4:30 pm or 8:30-5:00 pm ET)
- Remote workdays require a stable, secure, quiet, and compliant workspace
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$19.81 - $28.30/Hourly
Grade
3
EEO Statement:
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.
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