Special Investigations Unit Claims Specialist

About the role

Candidates must reside in Michigan within a reasonable commuting distance of our Okemos, MI office for team meetings, collaborative sessions, and training.

Responsibilities

• Prepares Focused Review dental claims so appropriate determinations can be finalized with correct procedure policies and bypasses in place.
• Adjudicates claims, analyzes documents, maintains claims records, and coordinates adjustments on difficult claims and inquiries.
• Identifies and investigates aberrant treatment behavior patterns, and conducts continuous investigation when needed.
• Conducts determinations and clarifies questionable treatment patterns with dental consultant, and records all consultant determinations in the Claims System.
• Investigates claim reconsiderations, inquiries, and adjustments and prepares claims for a second and/or third opinion when necessary.
• Provides dental expertise and/or interpretations of dental policies, procedure codes, and processing guidelines to internal and external contacts.
• Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

Requirements

• Associate's degree, technical, vocational, or business school with coursework relating to dentistry and two years' experience in chair side assisting.
• Advanced knowledge of dental terminology and dental procedures and the ability to read and interpret radiographs, electronic images and photos.
• Experience working with word processing and spreadsheet software.
• Effective verbal and written communication skills.
• Ability to resolve moderately complex problems and use independent judgment.
• Experience with Provider system; ETS; Client and Provider contracts is preferred.