Dental Specialist

Job Description

Job Description

Job Title: Dental Specialist 

Location: Pasadena, CA 

Job Type: Full-Time (Temporary Position) 

Department: Member Services 

Job Summary:

The Dental Specialist is responsible for reviewing, evaluating, and processing dental reimbursement requests accurately and efficiently in accordance with policy guidelines and dental coding standards. This role ensures the timely adjudication of requests while maintaining high levels of accuracy and compliance with state and federal regulations.

Key Responsibilities:

· Review submitted dental reimbursement requests for completeness, accuracy, and compliance with plan coverage and policy terms

· Interpret and apply plan benefits, CDT codes, and clinical documentation to adjudicate requests

· Determine eligibility, benefit levels, and payment amounts

· Approve or deny requests based on established criteria, documenting decisions clearly

· Request additional information or supporting documentation from the member and providers when necessary

· Communicate with dental offices, patients, and internal departments to resolve discrepancies

· Maintain daily productivity and accuracy standards as set by the department

· Identify and report billing errors, fraud, or abuse in compliance with regulatory guidelines

· Examine dental claims to ensure accuracy, completeness, and compliance with insurance policy requirements. This includes assessing claims for procedures ranging from cleanings to surgery

· Enter request data and notes accurately into the claim processing system

· Stay current on dental procedures, CDT codes, insurance policies, and regulations (e.g., HIPAA)

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Qualifications:

· Education: High school diploma or equivalent required; associate degree or training in dental/medical billing preferred

· Experience:

o At least 1 year of experience in dental claims processing, dental billing, or insurance operations

o Familiarity with dental coding (CDT) and terminology

· Skills:

o Strong analytical and decision-making skills

o Excellent attention to detail and organizational abilities

o Effective verbal and written communication skills

o Proficiency in dental or medical claims processing systems

o Basic knowledge of Microsoft Office (Excel, Outlook, Word)

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Preferred Qualifications:

· Experience with dental benefit plans, including PPO, HMO, and Medicaid

· Prior work with claims processing platforms or dental practice management software

· Certified Dental Coder or similar certification (optional but beneficial)

· Bilingual (Spanish or other languages) a plus

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Work Environment:

· Standard office setting or remote work, depending on the organization

· Sitting for extended periods and using computers for data entry

· Fast-paced environment with productivity goals

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