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Role Description

Responsible for ensuring departmental tasks are completed in order to meet client turnaround times for claim payment and authorization determination. Manages all special handling requests to support both internal and external requirements.

• Manages daily work plan and distributes work out to the team to ensure client turnaround times are met.
• Provide second tier support to data entry processors by providing direction on how to resolve submission discrepancies according to client business rules.
• Manage specialized workflows to support client requests that deviate from standard processes and procedures. Coordinate resolution with required departments as necessary.
• Responsible for ensuring all reporting is reviewed, work queues are completed, and open issues are resolved prior to claim payment and authorization review. Proactively communicate readiness to transfer data to appropriate departments.
• Proactively communicate potential issues to management to allow for timely resolution.
• Ability to multitask within multiple modules of the Enterprise System to retrieve and research information along with processing any submission requests or special handling requests received.
• Comprehensive understanding of client processing guidelines and requirements.
• Process primary insurance carriers EOB’s for appropriate payment.
• Act as a subject matter expert for items sent to the Claims Intake team; answering questions to internal and external contacts and resolving matters that may fall outside of the established workflows.
• Proactively bring forward provider submission errors and collaborate with internal teams for provider outreach and education.
• Manage and process urgent operating room (OR) authorization requests submitted via fax and coordinate with the authorization team to ensure timely review and determination outcome.
• Resolve provider data discrepancies submitted electronically that prevent the submission to proceed through the system. Utilize outside databases to validate provider credentials.
• Assists with training support of internal team members.

Additional Responsibilities:

• Partner with Claims Intake team in completing all other tasks as necessary to ensure accurate and timely completion of work to meet our client service level agreements.
• Assist with special projects requests assigned by leadership team.

Qualifications

• High school diploma or equivalent.
• 1+ year(s) of related experience such as claim processing, dental assistant, dental front office administration and/or health/dental insurance such as managed care operations, accounts receivable and/or billing environment.
• Successfully complete a pre-employment online alphanumeric data entry assessment.
• Ability to work effectively with multiple interruptions.
• Ability to organize work appropriately to meet deadlines.
• Excellent attention to detail.
• Ability to multi-task.
• Ability to utilize resources to solve problems independently.
• Excellent critical thinking skills.
• Excellent verbal and written communication skills.
• Basic Microsoft applications.
• Knowledge of insurance EOB’s and billing codes.
• Knowledge of American Dental Association (ADA) forms, UB-04 Facility Claim form or Member Reimbursement forms.

Requirements

• Bachelor’s Degree in a related field (preferred).
• 2+ years of medical, dental or vision claim processing (preferred).