Dental Claims Resolution Specialist

Dental Claims Resolution Specialist (Administrative)

The Dental Claims Resolution Specialist will be responsible for investigating, recovering and resolving all types of claims. Educate and inform members and providers of program coverage and limitations for claims within contract requirements. Use critical thinking, research and problem-solving skills to navigate through the complexities of a member's health benefits and their respective claims while remaining within the program guidelines.

Salary: $17.75 an hour plus $5.36 Health and Welfare.

• Maintain an ongoing responsibility for assigned claims inquiries which entails assessment, education and coordination for members/health care providers while keeping a detailed record within the internal database
• Establish and maintain positive relationships with members, providers and our claims contractor
• Demonstrates great depth of knowledge/skills in own function
• Request and manage medical records to help determine potential program coverage and communicate results to the members
• Completion of system generated tasks, including documenting all results as required
• Prepare comprehensive reviews and summaries for claim appeals
• Point of contact for internal departments to answer questions relative to member claims
• Work with internal department to request code additions or other avenues to resolve issues in the program where appropriate
• Understand the claim lifecycle and ensure that claims are resolved through the entire process
• Solves moderately complex problems on own
• Proactively identifies solutions to non-standard requests/inquiries
• Work with the leadership team to resolve complex issues as needed
• Able to handle emotionally charged phone calls and ability to deliver unfavorable claim outcomes
• Ability to communicate complex program criteria into easily understood summaries in both oral and written communication
• Validation of claim coverage in relation to program guidelines
• Plans, prioritizes, organizes and completes work to meet established objectives and metrics
• Complete activities and reporting as required by the fraud, waste and abuse plan
• Monitor progress of Accounts Receivable targets and plans within contract KPIs
• Performs periodic and month-end balancing and reporting activities
• Perform research/verification of identified claims to identify payment/over payment issues/accuracy
• Work with payers/providers to review claim information and identify issues related to payment accuracy
• Document and communicate outcomes of claims investigations/over payment reviews to applicable stakeholders