Sr. Dental Benefits Specialist

Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits that millions of federal employees and retirees, military retirees and their families have counted on since 1937. Offering one of the largest health and dental benefit provider networks available to federal employees in the United States, G.E.H.A empowers health and wellness by meeting its members where they are, when they need care.

G.E.H.A has one mission:
To empower federal workers to be healthy and well. The Senior Dental Benefits Specialist is responsible for second-level appeal documentation integrity, clinical review coordination between G.E.H.A's third-party administrator (TPA) and clinical review vendor, and post-payment claims audits for G.E.H.A's dental programs. This role serves as G.E.H.A's internal dental subject matter expert for benefit interpretation, CDT coding, claims accuracy, and appeal documentation defensibility.

Operating as a senior individual contributor within a federally regulated dental benefits program, the Specialist independently determines documentation sufficiency, identifies when additional clinical review or policy interpretation is required, defines the scope of directed claim reviews, and prepares defensible appeal and audit findings without routine review. The role ensures appeal files, determination records, and audit findings are complete, objective, and audit-ready for internal review, OPM review, or federal audit.

Second-Level Appeal Documentation & Clinical Review Ownership Ensure second-level appeal documentation is accurate, complete, defensible, and consistent with G.E.H.A’s plan provisions, benefit policies, and clinical appropriateness criteria; independently determine whether documentation is sufficient, whether additional clinical review is required, and whether the case record supports the final determination. Own the end-to-end clinical review pathway between G.E.H.A's third-party administrator (TPA) and the clinical review vendor, providing a well-organized case summary and complete supporting documentation to support timely, well-informed determinations, and holding both parties accountable to established turnaround standards.

Ensure all appeal documentation and clinical review coordination are completed within established internal turnaround standards, maintaining accurate tracking and documentation of case status, review rationale, and outcome for every case. Review determination letters and supporting correspondence for accuracy and completeness, ensuring the outcome, rationale, and any applicable next steps are clearly documented for the member or provider. Maintain organized appeal case files in accordance with G.E.H.A's documentation standards, ensuring records are audit-ready at all times.

Identify patterns or trends in appeal volumes, denial reasons, or determination outcomes and surface findings to the Manager, Dental Product for strategic or operational action. Serve as the escalation point for complex or contested appeal documentation questions, determining when additional clinical input or policy interpretation is required. Post-Payment Claims Audit & Payment Accuracy Conduct post-payment claims audits on a random basis and as directed, reviewing paid dental claims against G.E.H.A's plan provisions, CDT coding standards, and benefit limitations to identify over payments, billing errors, or coding irregularities.

Apply independent analytical judgment to CDT codes, dental benefit structures, and common billing patterns to evaluate claim accuracy and flag potentially improper payments with clear, well-documented findings. Prepare audit findings reports that are…