Dental Claims Resolution Specialist (Administrative)
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.
Primary Responsibilities:
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 databaseEstablish and maintain positive relationships with members, providers and our claims contractorDemonstrates great depth of knowledge/skills in own functionRequest and manage medical records to help determine potential program coverage and communicate results to the membersCompletion of system generated tasks, including documenting all results as requiredPrepare comprehensive reviews and summaries for claim appealsPoint of contact for internal departments to answer questions relative to member claimsWork with internal department to request code additions or other avenues to resolve issues in the program where appropriateUnderstand the claim lifecycle and ensure that claims are resolved through the entire processSolves moderately complex problems on ownProactively identifies solutions to non-standard requests/inquiriesWork with the leadership team to resolve complex issues as neededAble to handle emotionally charged phone calls and ability to deliver unfavorable claim outcomesAbility to communicate complex program criteria into easily understood summaries in both oral and written communicationValidation of claim coverage in relation to program guidelinesPlans, prioritizes, organizes and completes work to meet established objectives and metricsComplete activities and reporting as required by the fraud, waste and abuse planMonitor progress of Accounts Receivable targets and plans within contract KPIs (reword to remove A/R)?Performs periodic and month-end balancing and reporting activitiesPerform research/verification of identified claims to identify payment/overpayment issues/accuracyWork with payers/providers to review claim information and identify issues related to payment accuracyDocument and communicate outcomes of claims investigations/overpayment reviews to applicable stakeholders
