Dental Claims Review Analyst - Remote

EmblemHealth; New York (NY); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading company in health insurance seeks a Claims Analyst in New York. The role involves analyzing and processing claims while utilizing clinical expertise and collaborating with various departments to ensure efficient claim resolution. Ideal candidates will possess relevant qualifications and experience in a clinical environment.

Qualifications

• 2-3+ years of related experience in a clinical dental environment.
• Knowledge of claim processing policies and procedures.
• Proficient with MS Office tools.

Responsibilities

• Review and analyze claims based on clinical guidelines.
• Perform provider outreach for claim resolution.
• Investigate member benefits and policies for claims.

Skills

Problem-Solving

Communication

Analytical Skills

Education

Bachelor’s Degree

Certification as Dental Hygienist or Claims Coding

Tools

MS Office

Job description

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visitemblemhealth.com .

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 (Preferred)
• 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)

Security Disclosure

If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.

Pay Disclosure

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.

EEOC Statement

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

Sponsorship Statement

EmblemHealth may provide work visa sponsorship depending on factors such as business unit requirements, position nature, costs, and applicable laws and regulations.