Claims Examiner II

JOB DESCRIPTION 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. $37,269 - $75,346. ADDITIONAL INFORMATION 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. EQUAL EMPLOYMENT OPPORTUNITY STATEMENT 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. #J-18808-Ljbffr