Claims Specialist

The Claims Processing Representative is responsible for the independent adjudication of claims of primarily low to moderate complexity, ensuring accurate and timely processing in accordance with organizational policies, contractual obligations, and regulatory requirements. This role conducts research and investigation of claim-related issues-including eligibility determinations, provider status, and benefit verification-working to resolve inquiries through to completion whenever possible. Responsibilities Processes claims of low to moderate complexity across multiple claim types, ensuring accuracy, compliance, and adherence to established guidelines. Conducts detailed research and investigation of claim issues, including eligibility, benefits, and supporting documentation. Interprets and applies claims processing policies, procedures, and regulatory requirements, exercising sound judgment in resolving standard exceptions. Maintains accurate and complete documentation of claim determinations and supporting rationale, ensuring QA readiness and transparency. Applies analytical and problem-solving skills to resolve discrepancies efficiently and within established service levels. Determines appropriate claim pricing and next steps, including routing or submitting claims to higher-level roles when necessary. Consistently meets or exceeds established productivity, quality assurance, and service metrics. Qualifications Minimum of 3 years' experience in the dental industry or claims processing role preferred; Knowledge and experience in benefit determination and dental terminology preferred; Strong verbal and written communication skills; Detail-oriented with a commitment to accurate and efficient claims processing. Demonstrated commitment to the company's core values of integrity, adaptability, service-focused, accountability, curiosity, and community. #J-18808-Ljbffr