Dental Claims Processor I

Moda Health•Milwaukie, OR

6d•Hybrid

About The Position

The Dental Claims Processor I reviews claims to determine why they did not auto-adjudicate, makes corrections as necessary, and processes claims according to processing policies and contract provisions. This hybrid position is based in Milwaukie, Oregon. The processor uses contract notes and a processing manual to apply group-specific and standard contract benefits, determine eligibility and coverage, and enter information so claims are paid correctly. The role also involves documenting claim activity, sending clinical requests and missing-information letters, performing some manual benefit calculations, and analyzing pended claims. The work takes place in an office environment with extensive computer and keyboard use, frequent phone communication, and interaction with internal teams. Work beyond the standard workweek, including evenings and occasional weekends, may be required to meet business needs.

Requirements

High school diploma or equivalent.
10-key proficiency of 105 kspm net on a computer numeric keypad.
Type at least 35 wpm net on a computer keyboard.
Ability to achieve and maintain quality and quantity standards.
Legible handwriting.
Good reading, verbal, and written communication skills.
Ability to listen, communicate clearly, and interact professionally, patiently, and courteously with coworkers and a supervisor.
Analytical, problem-solving, and decision-making skills.
Detail orientation, good memory retention, and ability to shift priorities.
Good organizational skills and ability to work under pressure, handle varied functions, and meet timelines.
Ability to interpret contracts and apply Moda policies and procedures to claims processing.
Ability to arrive at work on time and attend work daily.
Ability to maintain confidentiality and project a professional business image.
Ability to navigate multiple computer screens.
Reliable, high-speed, hard-wired internet connection to support remote or hybrid work.
Comfort with being on camera for virtual training and meetings.
Willingness to work beyond the standard workweek, including evenings and occasional weekends, to meet business needs.

Nice To Haves

Knowledge of dental terminology and ADA codes.
Data entry experience dealing with all types of plans and claims.

Responsibilities

Review claims to determine why they did not auto-adjudicate and analyze pended claims.
Make corrections as necessary and process claims according to processing policies and contract provisions.
Use contract notes and a processing manual to apply group-specific and standard contract benefits to pended claims.
Determine plan benefits, eligibility, whether claims qualify for benefits, expected system payment, and the information needed to ensure correct payment.
Document claim activity clearly and concisely, and analyze and interpret existing file notes and documentation.
Send clinical request and missing-information letters.
Perform some manual calculation of benefits.
Perform other duties as assigned.