Government Programs Professional Review Claims Specialist

Job Title:

Number of Positions:

Location:

Location Specifics:

Job Summary:

Candidates must reside in Michigan within a reasonable commuting distance of our Okemos, MI office for team meetings, collaborative sessions, and training. 

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation.

At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do – from taking charge of our careers, to helping colleagues and lending a hand in the community. 

Position Description:

To analyze and adjudicate dental claims with complicated treatment plans to ensure accurate benefits administration.

Primary Job Responsibilities:

• Analyzes and processes dental claims so appropriate determinations can be finalized with correct procedures, policies, and bypasses; adjudicates claims, and maintains claim records.
• Administers claim processing guidelines/standards, Delta USA processing policies, group contracts, provider agreements, and state laws applicable to claims adjudication.
• Investigates difficult provider reconsideration requests, makes determinations, performs or coordinates adjustments; prepares claims for a second and/or third opinion when necessary and consults with contracted dentists on questionable treatment cases.
• Pre and post-screens claims and/or inquiries for dental consultant(s); reviews and prepares claims for and coordinates external dental consultant activities.
• Provides dental expertise and/or interpretation of dental policies, procedures codes, and processing guidelines to internal and external contacts.
• Organizes, creates, and performs defined test cases on claims processing system, and documents/reports status of testing including recommendations for improvements. Analyzes and compiles information/data for reports to control and/or monitor claims inventory.
• Researches, coordinates, and adjudicates Third Party Liability claims and recoveries; compares member information, prepares claims, and performs adjustments as necessary to ensure proper Third Party Liability (COB) adjudication.

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

#LI-Remote

Minimum Requirements:

Position requires an associate's degree, technical, vocational, or business school with coursework related to dentistry, two years of experience in chair side assisting, and a RDA or RDH licensure. Will accept any suitable combination of education, training, or experience.

Position requires advanced knowledge of dental terminology and dental procedures and the ability to read and interpret radiographs, electronic images and photos; experience working with word processing and spreadsheet software; effective verbal and written communication skills; ability to resolve complex problems and use independent judgment; experience with provider system; client contracts and Roosevelt is preferred.

The company will provide 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.