Claims Processor

NationsBenefits • Plantation, FL

2d

About The Position

The Claims Processor accurately adjudicates dental claims for approximately 400,000 members effective January 1, 2027. The role reviews, prices, and pays or denies claims according to plan benefits, state regulations, and company policies, and routes claims requiring clinical judgment to the clinical review process. Utilization review recommendations are provided by the partner Fluent, whose clinical dental directors cover all fifty states.

The position processes claims and related inquiries while meeting productivity, quality, turnaround, and regulatory requirements. It also participates in training, quality audits, and user acceptance testing ahead of go-live. The work is primarily sedentary and computer-based in a production environment, with standard hours and possible overtime during launch and peak periods.

Requirements

• High school diploma or equivalent required.
• At least 2 years of dental or health insurance claims processing experience required.
• Working knowledge of CDT codes, dental terminology, EOBs, and coordination of benefits.
• Experience with a claims adjudication platform.
• Strong data entry accuracy and typing skills.
• Strong attention to detail, time management, written communication, and customer service skills.
• Ability to meet productivity and accuracy standards, including examples of 98% financial and 95% procedural accuracy.
• Proficiency in Microsoft Office and comfort using multiple systems and imaging viewers.

Nice To Haves

• Associate or bachelor's degree.
• Experience with Medicare Advantage, Medicaid, or commercial dental plans.
• Prior experience working alongside clinical review or utilization management partners.
• Bilingual in English and Spanish.

Responsibilities

• Adjudicate ADA/CDT-coded dental claims from work queues, applying member benefits, fee schedules, frequency and age limitations, waiting periods, deductibles, maximums, and coordination of benefits.
• Review pended claims, attachments, narratives, and x-rays for completeness and identify claims requiring clinical review.
• Refer claims to the hygienist team or Fluent for clinical recommendations, then correctly apply the recommendation and document the outcome.
• Process adjustments, reprocessing, refunds, overpayment recoveries, and corrected claims.
• Research and resolve claim inquiries from Customer Service, providers, and members, and clearly document actions in claim notes.
• Meet daily productivity, quality, and turnaround targets, including state prompt-pay timelines.
• Identify trends, system errors, and benefit configuration issues and escalate them to leadership.
• Protect PHI and follow HIPAA, privacy, and compliance requirements.
• Participate in training, quality audits, and user acceptance testing ahead of go-live.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED