Medicare/Medicaid Claims Reimbursement Specialist

Position Summary:

Reporting to the Director, Claims Operations and Quality Assurance, the Claims Sr. Analyst plays a critical role in ensuring accurate, compliant, and timely reimbursements within the scope of MassHealth and Medicare Advantage programs. Under the direction of the Director of Claims Operations and Quality Assurance, this role is responsible for the end-to-end review, analysis, and resolution of complex reimbursement issues - including underpayments, overpayments, and disputes. The Claims Sr. Analyst serves as a subject matter expert on Medicaid (MassHealth), Medicare, and commercial payment methodologies and supports audit, compliance, and provider engagement initiatives. This role also provides support in managing provider disputes and escalations requiring detailed pricing and reimbursement validation.

Supervision Exercised:

• No, this position does not have direct reports.

Essential Duties & Responsibilities:

• Analyze MassHealth and Medicare claim reimbursements to ensure compliance with contractual terms, state and federal regulations, and internal payment policies.
• Resolve provider inquiries and disputes related to pricing discrepancies, contract interpretation, and fee schedule issues.
• Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances, and Configuration teams to validate and resolve reimbursement concerns.
• Conduct retrospective audits to identify systemic payment issues and recommend resolution pathways.
• Interpret and apply MassHealth fee schedules, All-Payer Rate Setting regulations, and CMS payment methodologies (e.g., DRG, APC, RBRVS).
• Support provider appeal reviews and internal payment integrity investigations by providing reimbursement validation.
• Escalate systemic or high-impact discrepancies to the Director of Claims Operations and Quality Assurance for further investigation or configuration updates.
• Document all research, findings, and outcomes in claims systems (e.g., Salesforce, Facets) in compliance with audit standards and MassHealth requirements.
• Maintain awareness of MassHealth transmittals, billing guides, and program updates to ensure adherence in payment practices.
• Ensure SLA compliance for inquiry resolution, appeal response times, and post-payment audits.
• Assist in the resolution of complex provider disputes and escalations, including direct support to leadership in pricing determinations and dispute case documentation.

Working Conditions:

• Standard office conditions.

Required Education (must have):

• N/A

Desired Education (nice to have):

• Associate's or Bachelor's degree in Health Administration, Finance, or related field preferred.
• Certified Professional Coder (CPC) - AAPC
• Certified Claims Professional (CCP)
• Other AHIMA or Medicaid billing-related certifications
  

Required Experience (must have):

• 3+ years in healthcare claims processing, provider reimbursement, or payment integrity.
• Experience with core claims platforms such as Facets, QNXT, or Amisys.

Desired Experience (nice to have):

• Prior experience working with MassHealth and Medicare Advantage reimbursement rules is strongly preferred.

Required Knowledge, Skills & Abilities (must have):

• Proficiency with Excel and reporting tools for data analysis.
• Understanding of provider contracts, rate tables, and state-set payment methodologies.
• Strong problem-solving and analytical skills.
• Effective verbal and written communication with both internal stakeholders and providers.
• Meticulous attention to detail and documentation standards.

Required Language (must have):

• English

Desired Knowledge, Skills, Abilities & Language (nice to have):

• Knowledge of Facets, MassHealth, and CMS is a plus.