This is a remote role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA. Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our

Works with the Director, Medicare Advantage Program and Innovation Operations, and health plan business areas/departments to execute the annual Medicare Advantage work plan which includes standard work and large, complex, cross functional projects Identifies and escalates for visibility any issues, risks or decisions needed to prevent or remove barriers to completing task

Serve as the primary liaison for members and providers for all lines of business including MassHealth, and Commercial members regarding general program inquires such as eligibility verifications, authorizations, referrals, claims, material fulfillment, address changes and Primary Care Physician assignments as well as member related policy and procedures. The CSP must be a

Supports reserving analysis and communication of financial results to senior leadership. Responsible for monthly IBNR and other actuarial accruals (MLR Rebate, risk adjustment, PDR, Provider Bonus, High Cost Risk Pool, etc.). Quarterly forecasting of Mass General Brigham Health Plan financial statements for purposes of business planning. Responsible for monthly MLR model

Review and research assigned claims by navigating multiple systems and platforms and accurately capturing the data/information necessary for processing (e.g., verify pricing/Fee Schedules, contracts and Letters of Agreement, prior authorizations, applicable member benefits) Pay, deny, or pend claims as appropriate in a timely manner. Manually enters claims into QNXT as ne

Evaluate and analyze data using T SQL, Excel, and PowerBI and other BI tools to design, develop, and test analytic solutions from various data sources. Analyze, Interpret, and validate results of analytic, BI, and reporting solutions produced by the reporting, BI, and Data Architecture teams. Create and revise process flows, data flows, data requirement specifications, us

Responsible for ensuring all 834 transactions are being correctly reconciled. Work closely with IT to set requirements and user stories, as well as signing off on results and approving changes being promoted to production. Lead teams to enable system automation in Enrollment to reduce administrative costs, improve member experience and operational efficiency. Engage, empo

This is a remote role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA. Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our

This is a hybrid role that will require an onsite presence to the office 1x/month Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative sol