IV (Dental)

Univera Healthcare•Buffalo, NY

About The Position

The Claims Examiner resolves a wide variety of claims transactions, which may include claim entry, adjudication, and adjustment of simple or complex claims. Work is performed in accordance with Member Touchpoint Measures (MTM), the Inter-Plan Scorecard, the FEP Performance Incentive Plan (PIP), corporate policies, National Committee for Quality Assurance (NCQA) standards, and mandated requirements. The role is classified at four levels, differentiated by the complexity and independence of assignments, decision-making responsibility, and contribution as a resource to colleagues. Level I handles front-end transactions, including eligibility, claim entry, member and provider matching, and claim processing. The examiner researches and processes claims, requests missing information, collaborates with internal departments and customers, identifies patterns and potential trends, and escalates issues when appropriate. The role also requires ongoing learning, attention to quality and detail, professionalism, adherence to procedures and privacy policies, reliable attendance, and other duties assigned by management. Level II adds complex claim processing and limited adjustments, root-cause analysis, recommendations for solutions, participation in change-related decisions, risk communication, efficient resolution using current policies and business requirements, and assistance to other processors. Level III adds high-profile claim processing and all adjustments, initiating action to resolve risks, peer training, and taking on higher-level responsibilities or escalated issues. Level IV adds mass adjustment or scripting management, analytical support, high-profile adjustments, mentoring and coaching, independent risk management with strategic resolution plans, and facilitating peer-level meetings. The position requires a high school diploma or equivalent. Relevant customer service or claims processing experience is preferred. For the B version, a valid New York State Independent Adjuster License and ongoing renewal maintenance are required. Higher levels require progressively greater experience and demonstrate increased analytical ability, independence, business judgment, or mentoring capability. Physical requirements include communicating by phone, working at a computer workstation for extended periods, and travel across the Health Plan service region for meetings or training as needed.

Requirements

High school diploma or equivalent.
Basic computer skills, including the ability to navigate a Windows environment and work across multiple programs and applications simultaneously.
Ability to self-manage, multitask, and efficiently resolve moderately complex claims processing and simple adjustment transactions.
Tasks and duties are performed under the guidance of a lead or supervisor.
Capacity to continuously develop skills necessary for growth.
For the B version at all levels: valid New York State Independent Adjuster License and continued administrative maintenance of renewals.
Level II and above: at least one year of progressive experience in claims processing, customer service, or insurance-related positions; ability to analyze and resolve complex situations or transactions; understanding of coordination of benefits (COB) determination; strong reasoning and problem-solving skills.
Level III and above: at least three years of progressive experience in claims processing, customer service, or insurance-related positions; strong business acumen; ability to work independently with a high level of accuracy.
Level IV: at least five years of progressive experience in claims processing, customer service, or insurance-related positions; proven ability to mentor and coach junior specialists.
Ability to hear, understand, and speak clearly while using a phone, with or without a headset.
Ability to work sitting and/or standing at a workstation while viewing a computer and using a keyboard, mouse, and/or phone for three or more hours at a time.
Ability to travel across the Health Plan service region for meetings and/or training as needed.

Nice To Haves

Relevant customer service or claims processing experience is preferred.

Responsibilities

Process front-end transactions such as member eligibility, claim entry, member and provider matching, and claim processing.
Process, enter, adjudicate, adjust, and research claims in accordance with procedures, policies, contracts, and riders.
Request needed information through system-generated letters or phone calls.
Identify patterns and trends that may affect quality, claim inventory, customer experience, or operations, and escalate or investigate them as appropriate.
Collaborate with internal departments and communicate effectively with internal and external customers.
Participate in learning opportunities related to regulations, systems, procedures, and role skills.
Maintain professionalism, self-direction, quality, attention to detail, and compliance with desk-level procedures.
Support the company mission and values, follow the Corporate Code of Conduct, and protect member privacy.
Maintain regular and reliable attendance and perform other functions assigned by management.
At Level II, handle complex claims and limited adjustments; identify root causes, recommend solutions, contribute to decision-making, communicate risks to leadership, apply current policies, and assist other processors.
At Level III, handle high-profile claims and all adjustments; initiate action to resolve risks, provide peer-to-peer training, and assist with escalated issues or higher-level responsibilities.
At Level IV, manage mass adjustment or scripting processes, support analytical work, handle high-profile adjustments, mentor and coach peers, develop strategic plans to resolve risks, and facilitate peer-level meetings.
Travel across the Health Plan service region for meetings and/or training as needed.

Benefits

Group health and/or dental insurance may be included in the total rewards package.
Retirement plan may be included in the total rewards package.
Wellness program may be included in the total rewards package.
Paid time away from work may be included in the total rewards package.
Paid holidays may be included in the total rewards package.

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