Job Description
Role Description
- To direct and assist in cases involving the resolution of dental benefit determinations and analysis of provider inquiries including claims, record changes and discrepancies, and credentialing and recredentialing updates submitted to Professional Relations.
- Researches, analyzes, and resolves cases involving compliance issues including but not limited to:
- Balance billing
- Non-delivery of care
- Quality of care
- Anti-fraud hotline
- Internal referrals
- Appeals
- Communicates to internal and external customers to ensure understanding of the corporation's programs and procedures and in resolving claims processing problems.
- Works directly with Provider Records, Customer Service, Focused Review, and other departments to research current record status, claims questions, and appeals.
- Prepares responses to dental claim inquiries so appropriate determinations can be finalized with correct procedure policies and bypasses in place, adjudicates claims, analyzes documents, and maintains claims records, as well as coordinates adjustments on difficult claims and inquiries.
- Prepares documentation and claims for adjustments and works with Records and Customer Service to ensure adjustments are completed.
- Performs other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.
- Qualifications
- Associate's degree in accounting, business administration, dental assisting or hygiene, or a related field.
- Four years of experience in a position requiring knowledge of dental terminology, dental procedure codes, or dental office billing and record keeping practices within a provider office.
- Experience administering dental benefit contracts within the insurance industry or identifying, analyzing, and resolving compliance issues based on policies and procedures outside of the insurance industry.
- Knowledge of word processing, spreadsheet, and database applications.
- Strong verbal and written communication skills.
- Strong analytical skills.
- Ability to work independently and as part of a team.
- Ability to manage multiple assignments with competing deadlines.
- Ability to identify and resolve problems using independent judgment.
- Requirements
- Equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.
Apply tot his job
Apply To this Job