Position Summary: Responsible for reviewing, analyzing and processing all claims for the focused review process, including claims that are not able to be processed and closed by Claims Operations. This position possesses strong understanding of DentaQuest administrative and contractual policies and procedures; represents DentaQuest in a professional manner at all times.
RESPONSIBILITIES:
Supports Corporate goals for claims processing production and accuracy by assuring dental services are approved or denied in accordance with market contract eligibility requirements.
Ensure accuracy of claims by reading and interpreting x-rays, models, photos and/or patient charts for necessity.
Manage questionable claims that require clinical expertise in the decision process by referring to a consultant for further review and final decision.
Support eligibility process by approving dental services that meet eligibility requirements and deny those that are ineligible. Ensure completeness by requesting any additional information from provider offices when appropriate and communicating outcomes to providers and/or members.
Determine eligibility and disallow and/or deny claims by following administrative guidelines.
Works with level II benefit examiners to learn the claim processing rules in addition to becoming proficient on the claims systems and gaining an understanding of processing of claims.
Provide customer service support by offering services as required within DentaQuest. May include assisting other departments in resolving inquires or complaints into specific claims or having direct contact with providers and/or members.
Support UM Manager efforts by tracking and reporting results of focused review claim process, reporting of aberrant billing patterns and/or behaviors of providers and assisting in analysis of statistical data as requested.
Improve processes and productivity of company by communicating with management.
Design and meet personal developmental goals by accepting training and guidance.
Requirements:
High School Diploma or equivalent.
5 years experience as a dental assistant or a degree in the dental field and 2 years experience with dental insurance coding.
Ability to interact in a cooperative, professional and effective manner with Provider offices, members, co-workers and company staff through all mediums (phone, in person, etc.).
Good communication, verbal and interpersonal skills.
Ability to work independently.
Good PC skills.
Ability to prioritize and organize multiple tasks and remain organized with multiple interruptions.
Ability to communicate via telephone.
Job Code: UM
Location: DentaQuest Ventures, MA
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position
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easier.
Just
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us
your
cover
letter
and
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to
dqvhr@dentaquest.com .
DentaQuest - 30+ days ago
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Indeed will send your application to dqvhr@dentaquest.com.
Please review all application instructions before applying.
