Claims Examiner

Claims Examiner

The Claims Examiner is responsible for administratively reviewing, analyzing, and adjudicating claims of varying complexity. This role focuses on non clinical decision making and ensures processing integrity by validating accuracy, completeness, eligibility, coverage, and benefit application across all claims systems. The Claims Examiner reviews supporting documentation, identifies discrepancies or potential fraud, resolves issues through coordination with internal and external stakeholders, and ensures all claim outcomes align with policy, regulatory requirements, and established procedures.

Responsibilities

Review and analyze claim submissions across all claims processing systems to ensure completeness, accuracy, eligibility, and appropriate documentation.

Verify coverage, pricing, authorizations, coordination of benefits (COB), and member eligibility in alignment with policy and regulatory requirements.

Apply policy provisions, benefit guidelines, and regulatory rules to accurately adjudicate all administrative claim types, including in and out of network claims.

Identify and address discrepancies such as incorrect billing, duplicate claims, or potential fraud indicators, escalating issues as appropriate.

Determine and apply accurate benefit payments in accordance with organizational standards and required regulatory timeframe.

Communicate with providers, enrollees, and internal teams to obtain missing or clarifying information and support timely claim resolution.

Investigate complex or questionable claims to validate documentation and ensure claim integrity.

Maintain accurate claim documentation and ensure compliance with HIPAA, privacy requirements, and all applicable regulations.

Meet established productivity and quality standards while contributing to process improvements and staying current with policy updates and regulatory changes.

Qualifications

3+ years of experience w/High School

2+ years' experience in a similar role; Associate degree preferred. Required to successfully complete claim examiner training and examinations.

Proficient in basic computer operations and Microsoft Office Suite programs (Excel, Outlook, Word, etc)

Effective written, verbal, and interpersonal communication skills to document claim decisions and communicate with internal partners and external clients

Ability to review information, identify the appropriate resolution, and recommend actions that ensure accurate, consistent, and outcome aligned results

High attention to detail to identify errors, inconsistencies, or missing documentation in claims

Ability to adapt quickly in fast-paced or changing environment

Ability to work effectively both independently with minimal supervision and collaboratively as part of a team

Knowledge of Delta Dental systems/organization and knowledge of health care industry issues preferred.

Base Pay Information The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental's assessment of the candidate's knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity. Pay Grade 14. $36,900 - $74,600

Additional Information

Behind the smile! We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. Our life-changing rewards package includes:

Competitive base and incentive pay

401(k) with robust matching and non-matching contributions

Rich medical & pharmacy benefits

100% employer-paid dental and vision benefits

Holistic wellbeing program with deep financial incentives

Generous paid time off plus 12 paid holidays and your birthday off

Culture of growth and learning: career development; tuition reimbursement; recognition program

Family support: adoption assistance, fertility treatment, child, elder & pet care assistance

Social responsibility and volunteer opportunities

Employee discount program

Fair Chance Ordinances and Criminal Background Considerations This position requires that the applicant undergo a background check. Qualified applicants with arrest or conviction records will be considered for employment in accordance with any applicable federal, state or local laws, including, but not limited to, the California Fair Chance Act, the Los Angeles County Fair Chance Ordinance, the City of Los Angeles Fair Chance Initiative for Hiring Ordinance, the San Francisco Fair Chance Ordinance, and/or New York Corrections Law Article 23-A. Important Work Authorization Information Please note, Delta Dental will not sponsor applicants for work visas for this position. #LI-Hybrid

About the Team

At Delta Dental, we're behind millions of smiles and counting. For over 68 years, we've served our communities by increasing access to affordable, quality care – but that commitment to care extends beyond the people we serve, to the dedicated employees who make those smiles genuine. We've come this far by building fair programs that offer opportunities for advancement, create meaningful connections and improve the lives of our employees and their families. Because we know that when we take exceptional care of each other, we can make a positive impact for all. We champion an inspirational workplace through our commitment to trust, service, excellence and innovation. Joining us means working for a company that offers stability and balance, opportunities for leadership at all levels, and a work environment focused on teamwork and camaraderie. Discover the smiling faces behind Delta Dental and experience our values and culture in action by connecting with us on social media. Follow Delta Dental Ins. on Facebook and Instagram, #LifeatDDins on Facebook and Instagram, Delta Dental Ins. on Twitter and Delta Dental Ins. on LinkedIn. If you've got an appetite for innovation and want to be a part of a team that's transforming the future of health care, join us! Since 1955, we have offered comprehensive, high-quality oral health care benefits to millions of enrollees and built the strongest network of dental providers in the country. The Delta Dental of California network includes affiliates Delta Dental Insurance Company; Delta Dental of Pennsylvania; Delta Dental of New York, Inc.; Delta Dental of the District of Columbia; Delta Dental of Delaware, Inc.; and Delta Dental of West Virginia, providing dental benefits to more than 31 million people across 15 states, the District of Columbia, Puerto Rico and the Virgin Islands. The company and its affiliates are part of Delta Dental Plans Association (DDPA), a not-for-profit national association based in Oak Brook, Illinois. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories. We offer vision coverage through DeltaVision in 15 states and the District of Columbia. Collectively, we deliver benefits to more Americans than any other dental insurance company. Delta Dental Ins. is an equal opportunity employer and is committed to providing a professional work environment free from discrimination and harassment. Individuals seeking employment at Delta Dental are considered without regard to race, ethnicity, color, age, sex, religion, national origin, ancestry, pregnancy, sexual orientation, gender identity, gender expression, genetic information, actual or perceived physical or mental disability, registered domestic partner status, caregiver status, marital status, veteran or military status, citizenship status, or any other legally protected category. Delta Dental is committed to providing equal employment opportunities to all employees and applicants for employment. Accordingly, we have adopted and maintain an Equal Employment Opportunity Policy, Harassment-Free Work Environment Policy, and Respectful Workplace policies and will not tolerate violations of these policies. Unfortunately, our Delta Dental Enterprise is unable to hire individuals residing in Alaska, North Dakota, Nebraska, Hawaii, Oklahoma, Vermont, Maine, West Virginia, New Hampshire, Wyoming, Puerto Rico, District of Columbia (Washington D.C.) or other US Territories at this time. Proof of eligibility to work in the United States must be provided if selected for hire. *Delta Dental includes: Delta Dental of California, Delta Dental Insurance Company, Delta Dental of Pennsylvania, and Delta Dental of New York

Job Info

Job Identification 3398

Job Category Claims Administration

Posting Date 07/14/2026, 08:54 PM

Job Schedule Full time

Locations Alpharetta, GA, United States