Claims Examiner I - Dental

Job Description

Job Description

SUMMARY: The Claims Examiner I is responsible for reviewing, analyzing, and processing healthcare claims to ensure accuracy, compliance, and timely adjudication. This position verifies coverage, evaluates documentation, and applies appropriate coding standards while adhering to regulatory requirements and organizational policies.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

1. Review and process claims for accuracy, completeness, and compliance with department policies and procedures, plan provisions and regulatory guidelines.
2. Verify member eligibility, coverage limits, and benefit coordination.
3. Analyze medical/dental records and billing codes (ICD, CPT, HCPCS, CDT) for proper coding and documentation.
4. Achieve or surpass departmental production and quality standards on a weekly, monthly, quarterly, and annual basis.
5. Review and process simple claim adjustments.
6. Actively participate in system testing when needed.
7. Maintain current department knowledge of plan documents, summaries of plan provisions and other plan materials.
8. Identify and recommend process improvements for internal workflow, system processes and updates to benefit plans.
9. Perform other job-related duties/special projects as assigned.
10. Comply with the policies of the Trust Fund, as set forth in the Employee Handbook.
11. Abide by organizational and HIPAA guidelines, privacy practices, and confidentiality.
12. Adhere to the company’s attendance policy.

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:

1. High School diploma or GED required
2. Registered Dental Assistant (RDA) License preferred
3. 2-3 years experience as a Claims Examiner
4. Knowledge of Current Procedural Terminology (CPT),Healthcare Common Procedure Coding System (HCPCS), Medical Terminology and/or Current Dental Terminology (CDT)
5. Knowledge with International Classification of Diseases (ICD) ICD-9/ICD-10 codes and guidelines
6. Able to utilize MS Office (Excel, Word and Outlook). Basic proficiency required