Claims Processing Representative I

Job Description

Job Description

Job Title: Claims Processing Representative I

Job Code: NE1005

Reports To: Claims Supervisor

FLSA Status: Non-Exempt

Grade Level: 21

Last Updated: April 2024

Position Summary:

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.

Essential Functions and Job Responsibilities:

1. (60%) Processes claims of low to moderate complexity across a variety of claims types. This work may include but is not limited to:

• Researching and investigating claims issues;

• Reviewing guidelines to understand protocols, policies and procedures;

• Documenting decisions and relevant information to ensure thorough information for future reviews;

• Researching details related to all aspects of the claim to ensure compliance with all relevant policies and laws;

• Utilizing a thorough understanding of claims policies and protocols to research and resolve exceptions;

• Demonstrating problem-solving skills to ensure prompt and accurate issue resolution;

• Determining appropriate pricing and resubmits claims for processing by next level roles when needed;

• Meeting or exceeding key metrics as outlined in individual goals provided to you in writing by your team lead;

• Participate in in-person meetings to learn new skills, train on system updates, build and maintain general knowledge and skills to help customers, stay abreast of departmental and organizational updates, engage in team building, maintain company culture, and foster relationships and build camaraderie with coworkers.

2. (20%) Resolves claims of low to high complexity across a single specialty or process area. This work may include but is not limited to:

• Resolving exceptions assigned to specialty claims or processes including foreign, implants, coordination of benefits, orthodontic, recovery and utilization management;

• Utilizing a thorough understanding of claims policies and protocols to research and resolve exceptions;

• Demonstrating problem-solving skills to ensure prompt and accurate issue resolution;

• Meeting or exceeding key metrics as outlined in individual goals.

3. (10%) Responds to emails, follows up and other forms of communication with other departments on outstanding claims issues requiring further intervention. This work may include but is not limited to:

• Processing emails from other departments;

• Collaborating with members of other departments to gather information and determine actions for resolution;

• Providing external outreach as needed to providers and members;

• Responding to claims processing emails as part of a regular rotation.

4. (10%) Rotates through the assignment of Dailies on a regular basis. This work includes but is not limited to:

• Completing tasks required to process the Dailies;

• Updating leaders on progress of assignments;

• Documenting outcomes of all tasks as appropriate;

• Collaborating with members of other departments to gather information and determine actions for resolution;

• Providing external outreach as needed to providers and members.

Regular and reliable attendance is required.

Other duties and responsibilities may be assigned.

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.

Competencies:

• Accountability

• Coachability

• Critical thinking

• Organizational skills

• Process focused

• Quality focused

• Resiliency

• Resourcefulness

Environment:

This position currently functions as a hybrid role working from both home and in-office environments. Any home office setting must be conducive to all guidelines outlined by the organization. This role is required to regularly attend in-person meetings, the frequency of which is determined by management based on departmental or organizational needs.

Physical and Other Demands:

Specific vision abilities required by this job include the ability to adjust focus. While performing the duties of this job, the employee is regularly required to sit. The employee is frequently required to use hands and arms to handle, feel, reach and operate a computer. This job requires substantial typing.

Additionally, this position requires working in a fast-paced environment that can be stressful at times based on the high volume of claims.

The ability to move from claim to claim in rapid succession is required.

This position requires a substantial amount of multi-tasking and ability to shift focus between tasks, screens, and systems to obtain data.

DDMO provides reasonable accommodation to qualified individuals with a known disability unless doing so imposes an undue hardship.

Employees must be able to successfully perform the essential functions of this role with or without a reasonable accommodation.

Disclaimer:

This job description is designed to provide a general overview of the requirements of the job and does not entail a comprehensive listing of all activities, duties or responsibilities that will be required. The organization reserves the right to modify this job description at any time; including assigning or reassigning job duties or eliminating this position at any time.