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Delta Dental of Missouri · 5 hours ago

Claims Processing Representative I

Saint Louis, Missouri, United States

Full-time

Hybrid

Mid Level

3+ years exp

Delta Dental of Missouri is looking for a sharp, organized, and motivated Claims Processing Representative I to join our team. In this role, you'll independently process dental claims, investigate eligibility issues, and ensure accuracy across a variety of claim types.

Insurance

Responsibilities

Processes claims of low to moderate complexity across a variety of claims types. This work may include but is not limited to:

Researching and investigating claims issues

Reviewing guidelines to understand protocols, policies and procedures

Documenting decisions and relevant information to ensure thorough information for future reviews

Researching details related to all aspects of the claim to ensure compliance with all relevant policies and laws

Utilizing a thorough understanding of claims policies and protocols to research and resolve exceptions

Demonstrating problem-solving skills to ensure prompt and accurate issue resolution

Determining appropriate pricing and resubmits claims for processing by next level roles when needed

Meeting or exceeding key metrics as outlined in individual goals provided to you in writing by your team lead

Participate in in-person meetings to learn new skills, train on system updates, build and maintain general knowledge and skills to help customers, stay abreast of departmental and organizational updates, engage in team building, maintain company culture, and foster relationships and build camaraderie with coworkers

Resolves claims of low to high complexity across a single specialty or process area. This work may include but is not limited to:

Resolving exceptions assigned to specialty claims or processes including foreign, implants, coordination of benefits, orthodontic, recovery and utilization management

Utilizing a thorough understanding of claims policies and protocols to research and resolve exceptions

Demonstrating problem-solving skills to ensure prompt and accurate issue resolution

Meeting or exceeding key metrics as outlined in individual goals

Responds to emails, follows up and other forms of communication with other departments on outstanding claims issues requiring further intervention. This work may include but is not limited to:

Processing emails from other departments

Collaborating with members of other departments to gather information and determine actions for resolution

Providing external outreach as needed to providers and members

Responding to claims processing emails as part of a regular rotation

Rotates through the assignment of Dailies on a regular basis. This work includes but is not limited to:

Completing tasks required to process the Dailies

Updating leaders on progress of assignments

Documenting outcomes of all tasks as appropriate

Collaborating with members of other departments to gather information and determine actions for resolution

Providing external outreach as needed to providers and members