• Job Description

  Req#: CLAIM001256

  TITLE: Claims Adjustment Clerk
  GRADE LEVEL: 17
  FLSA JOB STATUS: Non-Exempt
  DEPARTMENT: Claims Administration / Technical Operations
  REPORTS TO: Manager, Claims Administration / Operations Technical Manager
  DATE WRITTEN: March, 2023

  General Description
  Responsible for timely and accurate processing of dental claims.

  Responsibilities
  • Process claims submitted for payment. Either manually enter claims information via PC or review previously entered data for accuracy and completeness. Investigate and release all claims including those that suspend for system edits. Make additional claim payments when necessary. Submit refund requests if overpayment is discovered.
  • Process claims submitted for predetermination. Manually enter claims information via PC or review previously entered data for accuracy and completeness. Investigate and release all claims including those that suspend for system audits.
  • Review x-rays and make benefit determination or refer claim to consultant for decision.
  • Research and respond to escalated claims inquiries from Customer Service, Account Management and Group Accounts.
  • Prepare information request letters and/or contact dental offices via phone for information as needed.
  • Position may be assigned to override system pricing logic for certain groups and certain edits by utilizing the National Provider File and/or HIAA fee data and manually determine benefit payment amounts.
  • Position may be required to access electronic attachment files via internet sites of various vendors.
  • Position may be assigned to process claims received from foreign countries. This includes converting currency to US dollars and at times sending claims to outside translator.
  • Perform similar job-related special projects as assigned.
  • Identify and troubleshoot claims issues within system and report appropriately.
  • Meet and/or exceed daily and monthly claims processing metrics in order to ensure we are meeting our group guarantees.

  Education, Skills, Personal Attributes, and Experience Required
  • High School Diploma or equivalent.
  • Knowledge of dental terminology and/or insurance industry experience preferred.
  • Must have thorough knowledge of various transactions and policies utilized in claims administration functions.
  • Must have complete understanding of claims processing system functions, screens, and methods to resolve edit.
  • Ability to operate a calculator and PC keyboard.
  • Effective communication skills, both written and verbal, are required due to frequent communication with the public and internal customers.
  • Ability to work independently in a remote setting.
  • Ability to understand and keep up to date on DDPA/DDMO/DDSC claims processing policies and desktop business practices.
  • Ability to be a team player.
  • Position requires dependable attendance.
  • Proven subscription to the company’s core values of integrity, trust and respect, innovation, stewardship, excellence, and celebration.

  Work Conditions
  • General office working conditions which may require sitting for extended periods of time.

  Physical Requirements
  The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  Specific vision abilities require the ability to focus distant and near objects clearly. While performing the duties of this job, the employee is regularly required to sit, talk and hear. The employee is frequently required to use hands and arms to handle, feel and reach as well as operate a personal computer.

• About the company

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