Claims Processing Representative I

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.

If you thrive in a fast-paced environment, love solving problems, and have a keen eye for detail—this is your opportunity to make an impact.

Apply now to help us deliver accuracy and excellence in every claim.

Position Summary:

The primary responsibility of the Claims Processing Representative I is to independently process claims of low to moderate complexity.

This role researches and investigates claims issues including eligibility denials, provider suspensions, and student eligibility decisions to completion when possible.

This position resolves specialty claims or processes with low to moderate complexity and may leverage knowledge and skills to resolve complex claims in a single specialty or process area.

This position may escalate complex claims issues to next level roles when needed.

Essential Functions and Job Responsibilities:

1.

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.

2.

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.

3.

Responds to emails, follows up and other forms of communication with o...