Job Summary
Analyze, review, and process suspended claims, predetermination, and Service Requests based on industry standards and
clinical guidelines. Research, analyze, and investigate member benefits, policy and procedures for claims, grievance and appeal cases. Provide provider outreach where necessary to facilitate claim resolution and escalated service requests. Obtain claim records and supporting documentation needed for resolution. Collaborate with Dental Consultants to review and triage escalated claims, pre-determinations, and service requests. Integrate clinical expertise with industry knowledge to identify potential fraud patterns upon claim submission, alerting
dental director, and SIU team when applicable.
Responsibilities
• Review and analyze claims and pre-determinations within suspended system inventory using clinical expertise, industry standard guidelines, and benefit policy and procedures and make changes to procedure codes when necessary, using-supporting documentation (including radiographs, charting, correspondence) for payment or denial.
• Perform provider outreach when applicable for resolution.
• Investigate member benefits, policy and procedures for claims, grievance and appeal cases, and member and provider outreach via customer service and dental network team.
• Utilize specialized knowledge to analyze and resolve issues with dental claim coding.
• Initiate down-coding of submitted procedure codes that do not meet standards of care and/or the supporting documentation submitted with claim. Refer clinical denials to consultant for review with all necessary support information when needed.
• Identify potential claims problems or fraud patterns and refer to Lead analyst, Dental Director and SIU when necessary.
• Identify the need for new messages to clarify the Explanation of Benefits; contribute to/develop message changes.
• Recommend methods to improve the dental logic to boost system efficiency to Dental Director.
Qualifications
• Bachelor’s Degree.
• Certification as Dental Hygienist or Claims Coding Required
• 2 –3+ years of related experience, including experience in a clinical dental environment Required
• Additional experience/specialized training/certifications may be considered in lieu of Bachelor’s degree Required
• Knowledge of claim processing policies and procedures Required
• Proficient with MS Office - Word, Excel, PowerPoint, Outlook, Teams, etc. Required
• Strong communication skills - verbal, written, presentation, interpersonal Required
• Demonstrated analytical and problem-solving skills Required