Remote Government Programs Claims Specialist

Delta Dental of Michigan; Okemos (MI); On-site; USD 60,000 - 75,000; Full time

Job summary

Delta Dental of Michigan is seeking a Government Programs Professional Review Claims Specialist to analyze and adjudicate dental claims with complex treatment plans. The role requires interpreting policies, applying state laws, and coordinating with dental consultants to determine accurate benefits.

The successful candidate will possess an associate degree, two years of chair side assisting experience, and RDA/RDH licensure.

Qualifications

• Associate's degree, technical, vocational, or business school studies related to dentistry.
• Two years of chair side assisting experience.
• RDA or RDH licensure is required.

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.

Skills

Dental terminology

Radiographs interpretation

Communication skills

Education

Associate's degree

Tools

Word processing

Spreadsheet software

Job description

Delta Dental of Michigan is seeking a Government Programs Professional Review Claims Specialist to analyze and adjudicate dental claims with complex treatment plans. The role requires interpreting policies, applying state laws, and coordinating with dental consultants to determine accurate benefits.

The successful candidate will possess an associate degree, two years of chair side assisting experience, and RDA/RDH licensure.