Professional Services Claim Specialist (Review)

This is a remote position.

Delta Dental of Michigan, Ohio, and Indiana is a leader in dental benefits, plus so much more.

We improve oral health through benefit plans, advocacy and community support, and our corporate giving builds healthy, smart, vibrant communities for all. We devote our time, talents and financial resources to improve oral and overall health, and we invest in initiatives that support youth, education, workforce and economic development.

We are a force for good-part of the reason why employees find working at Delta Dental fulfilling. Delta Dental companies nationwide comprise the Delta Dental Plans Association, which provides coverage to more than 83 million Americans and operates two of the nation's largest networks of participating dentists. For more, visitwww.deltadentalmi.comandwww.vibrantcommunities.com, and apply online atwww.deltadentalmi.com/careers.

Job Summary:

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

Primary Job Responsibilities:

1.Analyzes and processes dental claims so appropriate determinations can be finalized with correct procedures, policies, and bypasses; adjudicates claims, and maintains claim records.

2. Administers claim processing guidelines/standards, Delta USA processing policies, group contracts, provider agreements, and state laws applicable to claims adjudication.

3.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.

4. Pre and post-screens claims and/or inquiries for dental consultant(s); reviews and prepares claims for and coordinates external dental consultant activities.

5.Provides dental expertise and/or interpretation of dental policies, procedures codes, and processing guidelines to internal and external contacts.

6. 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.

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

#LI-Remote

Position requires an associate's degree, technical, vocational, or business school with coursework related to dentistry and two years' experience in chair side assisting. 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 ETS is preferred.