Claims Processing Representative Job Saint Charles Missouri USA,Insurance

Position: Claims Processing Representative I
Location: St. Charles

Description 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 escalation complex claims issues to next level roles when needed.

Essential Functions and

Job 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 as provided by the 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
Collating information from other departments to determine actions for resolution
Providing external outreach as needed to providers and members

Regular and reliable attendance is required.

Other duties and responsibilities may be assigned.

Qualifications

Minimum of 3 years’ experience in the dental industry or claims processing role preferred
Knowledge and experience in benefit determination and dental terminology preferred
Strong verbal and written communication skills
Detail-oriented with a commitment to accurate and efficient claims processing
Critical thinking
Organizational skills
Quality focused

This position currently functions as a hybrid role working from both home and in-office environments. Any home office setting must be conducive to all guidelines outlined by the organization. This role is required to regularly attend in-person meetings, the frequency of which is determined by management based on departmental or organizational needs.

Physical and Other Demands

Specific vision abilities required by this job include the ability to adjust focus. While performing the duties of this job, the employee is regularly required to sit. The employee is frequently required to use hands and arms to handle, feel, reach and operate a computer. This job requires substantial typing.

Additionally, this position requires working in a fast-paced environment that can be stressful at times based on the high volume of claims.

The ability to move from claim to claim in rapid succession is required.

This position requires a substantial amount of multi-tasking and ability to shift focus between tasks, screens, and systems to obtain data.

DDMO provides reasonable accommodation to qualified individuals with a known disability unless doing so imposes an undue hardship.

Employees must be able to successfully perform the essential functions of this role with or without a reasonable accommodation.

Disclaimer

This job description is designed to provide a general…