Job Description
Dental Claims Processors
SUMMARY: A Dental Claims Processor adjudicates dental claims for payment based on summary plan descriptions.
ESSENTIAL DUTIES AND RESPONSIBILITIES: Include the following. Other functions may be assigned as business conditions change.
Adjudicate claims according to group guidelines. Review member history, eligibility, student status, coordination of benefits, fee schedules, member address, doctor address and other information to verify correctness.
Ensure adjudication of claims within Claims Department time restrictions (and/or alert supervisor/manager before work load falls behind these restrictions).
Review and process electronic claims.
Confer with dental consultants regarding high priority cases and/or unclear treatment plans.
Review check runs for accuracy. Make necessary adjustments when errors are found, including tagging checks for voiding.
Enter coordination of benefits information.
Handle claim adjustments taken by Customer Service and placed in daily Claims adjustment folders.
Assist group representatives with questions regarding eligibility, claim issues and plan guidelines when advised by Supervisors.
Research to find correct address when EOB's and checks are returned. When applicable, make corrections and resend.
Return claims to provider/member when essential information has been omitted from the claim form.
Make sure claim numbers and member name/identification numbers are written on all attachments to claim and given to the imaging department on a daily basis.
Fill out refund request forms and type refund request letters regarding overpayments made to members and/or providers.
Act as a back up to another processor (sorting and processing precerts and claims) when the other processor is absent.
Requirements QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience One year certificate from college or technical school; or one year minimum related experience and/or training; or equivalent combination of education and experience. Dental office experience strongly preferred.
COMPUTER SKILLS: Knowledge of Database software, strong alpha-numeric data entry skills.
OTHER SKILLS: Knowledge of ADA codes, dental procedures and terminology. Strong attention to detail.
Healthplex offers excellent compensation and working conditions. Employee benefits at Healthplex, Inc include:
Generous paid time off Medical Insurance Free dental coverage 401K Plan with employer contributions Group term life insurance
(1383)
