Claims Processor

Position Summary

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 in line with plan benefits, state regulations, and company policies, and routes claims needing clinical judgment to the clinical review process. Utilization review recommendations are provided by our partner, Fluent, whose clinical dental directors cover all fifty states.

Key Responsibilities

• Adjudicate dental claims (ADA/CDT coded) 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 to Fluent for clinical recommendations, then apply the recommendation correctly and document the outcome.

• Process adjustments, reprocessing, refunds, overpayment recoveries, and corrected claims.

• Research and resolve claim inquiries from Customer Service, providers, and members; document actions clearly in the claim notes.

• Meet daily productivity, quality, and turnaround targets, including state prompt-pay timelines.

• Identify trends, system errors, and benefit configuration issues and escalate to leadership.

• Protect PHI and follow HIPAA, privacy, and compliance requirements at all times.

• Participate in training, quality audits, and user acceptance testing ahead of go-live.

Qualifications

• High school diploma or equivalent required; associate or bachelor degree preferred.

• 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 (e.g., 98% financial and 95% procedural accuracy).

• Proficient in Microsoft Office; comfortable with multiple systems and imaging viewers.

Preferred

• Experience with Medicare Advantage, Medicaid, or commercial dental plans.

• Prior experience working alongside clinical review or utilization management partners.

• Bilingual (English/Spanish).

Performance Measures

• Claims processed per day (target to be set from final capacity model)

• Financial and procedural accuracy from audits

• Turnaround time and inventory aging within regulatory timelines

• Rework/adjustment rate

• Compliance and documentation quality