Claims Processing Representative I

Delta Dental Of Missouri•Fenton, MO

6d•Hybrid

About The Position

Delta Dental of Missouri is looking for a sharp, organized, and motivated Claims Processing Representative I to join our team. In this role, you'll independently process dental claims, investigate eligibility issues, and ensure accuracy across a variety of claim types. If you thrive in a fast-paced environment, love solving problems, and have a keen eye for detail—this is your opportunity to make an impact. Apply now to help us deliver accuracy and excellence in every claim. Position Summary: The primary responsibility of the Claims Processing Representative I is to independently process claims of low to moderate complexity. This role researches and investigates claims issues including eligibility denials, provider suspensions, and student eligibility decisions to completion when possible. This position resolves specialty claims or processes with low to moderate complexity and may leverage knowledge and skills to resolve complex claims in a single specialty or process area. This position may escalate complex claims issues to next level roles when needed.

Requirements

Strong verbal and written communication skills.
Detail-oriented with a commitment to accurate and efficient claims processing.
Regular and reliable attendance is required.

Nice To Haves

Minimum of 3 years’ experience in the dental industry or claims processing role preferred.
Knowledge and experience in benefit determination and dental terminology preferred.

Responsibilities

Processes claims of low to moderate complexity across a variety of claims types.
Researches and investigates claims issues.
Reviews guidelines to understand protocols, policies and procedures.
Documents decisions and relevant information to ensure thorough information for future reviews.
Researches details related to all aspects of the claim to ensure compliance with all relevant policies and laws.
Utilizes a thorough understanding of claims policies and protocols to research and resolve exceptions.
Demonstrates problem-solving skills to ensure prompt and accurate issue resolution.
Determines appropriate pricing and resubmits claims for processing by next level roles when needed.
Meets or exceeds key metrics as outlined in individual goals provided to you in writing by your team lead.
Participates in in-person meetings to learn new skills, train on system updates, build and maintain general knowledge and skills to help customers, stay abreast of departmental and organizational updates, engage in team building, maintain company culture, and foster relationships and build camaraderie with coworkers.
Resolves claims of low to high complexity across a single specialty or process area.
Resolves exceptions assigned to specialty claims or processes including foreign, implants, coordination of benefits, orthodontic, recovery and utilization management.
Responds to emails, follows up and other forms of communication with other departments on outstanding claims issues requiring further intervention.
Processes emails from other departments.
Collaborates with members of other departments to gather information and determine actions for resolution.
Provides external outreach as needed to providers and members.
Responds to claims processing emails as part of a regular rotation.
Rotates through the assignment of Dailies on a regular basis.
Completes tasks required to process the Dailies.
Updates leaders on progress of assignments.
Documents outcomes of all tasks as appropriate.
Regular and reliable attendance is required.
Other duties and responsibilities may be assigned.