Job Description

Job Description

Job Description

POSITION SUMMARY: This position is an integral part of the Operational team. In this role, the analyst will assist in various Operational processes including; new client setup, management of client, system configuration, claims resolution, and quality control of client related transactions. This individual will be a key resource to answer inquiries from other areas throughout the company. 

Essential Functions:

  Client Setup 

• Record system transactions to account for any changes in a client’s general and/or benefit information.
• Quality control checks of all system transactions.
• Serves as a resource to the organization regarding processing of client related information and transactions. 
• Maintain and process client renewal transactions. 

  System Configuration

• Research and configure system rules based off client benefit modifications, CDT updates and companywide policy changes.
• Propose new innovative rules to Management that enhance the claim processing system that will help build efficiencies and increase accuracy. 

Claims Resolution

• Plans, allocates, and monitors workflow to assure the accurate and timely completion of assignments within established production and inventory standards.
• Assists in the oversight of the processing and adjudication of claims by guiding the activities of the claims analysts; monitors and communicates corporate policies and procedures to assure a high level of accuracy and completeness within established production and inventory standards.
• Researches any unusual payments and refunds; processes the most complex type of claims which involve judgment and interpretation based on precedent, knowledge of the dental terminology, and a thorough understanding of the Corporation’s claims processing policies and procedures. 
• Research and resolve potential client overpayments and underpayments.
• Performs the overpayment recovery process to recoup overpayments made to the dentists.
• Interact regularly with Customer Service to answer claim-related questions. 

Data Analysis and Reporting

• Becomes knowledgeable with analytical tools and collaborates/recommends new operational reports to Data Analytics team. 

• Responsible for the quality of various operations department tasks including rule updates, coordination of benefit processing, ortho claims, internally entered claims pretreatments and client data management.

• Assists in the evaluation of all system releases to ensure accuracy and completion.
• Participates in pre-release testing with Project Management 

• Participates in special projects as required by management.
• Performs other duties as assigned.

Requirements: 

• High School Diploma or equivalent; Associates or Bachelor’s degree preferred.
• Excellent communication and organizational skills.
• Attention to detail and accuracy. 
• Prior knowledge of database programs preferred.

Entry Level Training Received (If any)

• Extensive training in claim, eligibility, and provider functions as well as workstation training.

Work Environment / Physical Demands:

• Typical office environment

Attendance Requirements:

• 40-hour workweek (M-F) as assigned and additional hours as required

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