Claims Processing Representative I

Delta Dental of Missouri • St. Louis, MO

2d • Hybrid

About The Position

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

Nice To Haves

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

Responsibilities

• Processes claims of low to moderate complexity across a variety of claims types, including researching and investigating claims issues, reviewing guidelines, documenting decisions, researching claim details for compliance, utilizing claims policies and protocols to resolve exceptions, demonstrating problem-solving skills, determining appropriate pricing, resubmitting claims, meeting key metrics, and participating in in-person meetings for learning, training, and team building.
• Resolves claims of low to high complexity across a single specialty or process area, including resolving exceptions for specialty claims (foreign, implants, coordination of benefits, orthodontic, recovery, utilization management), utilizing claims policies and protocols, demonstrating problem-solving skills, and meeting key metrics.
• Responds to emails, follows up, and communicates with other departments on outstanding claims issues, which includes processing emails, collaborating with other departments, providing external outreach to providers and members, and responding to claims processing emails.
• Rotates through the assignment of Dailies, including completing required tasks, updating leaders on progress, documenting outcomes, collaborating with other departments, and providing external outreach to providers and members.
• Regular and reliable attendance is required.
• Other duties and responsibilities may be assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed