Claims Processing Representative

Position Summary

The Claims Processing Representative I is responsible for the independent adjudication of claims of primarily low to moderate complexity, ensuring accurate and timely processing in accordance with organizational policies, contractual obligations, and regulatory requirements. This role conducts research and investigation of claim-related issues-including eligibility determinations, provider status, and benefit verification-working to resolve inquiries through to completion whenever possible.
The position demonstrates developing proficiency within a designated specialty or process area, applying technical knowledge and problem-solving skills to resolve exceptions and non-routine scenarios. More complex or escalated issues are referred to higher-level roles as appropriate.
 

Essential Functions and Job Responsibilities

1. Claims Adjudication and Issue Resolution. This work may include but is not limited to:
   • Processes claims of low to moderate complexity across multiple claim types, ensuring accuracy, compliance, and adherence to established guidelines.
   • Conducts detailed research and investigation of claim issues, including eligibility, benefits, and supporting documentation.
   • Interprets and applies claims processing policies, procedures, and regulatory requirements, exercising sound judgment in resolving standard exceptions.
   • Maintains accurate and complete documentation of claim determinations and supporting

rationale, ensuring QA readiness and transparency.

• • Applies analytical and problem-solving skills to resolve discrepancies efficiently and within established service levels.
  • Determines appropriate claim pricing and next steps, including routing or submitting claims to higher-level roles when necessary.
  • Consistently meets or exceeds established productivity, quality assurance, and service metrics.
  • Participates in ongoing development activities to build technical expertise, system proficiency, competencies, and organizational knowledge, while contributing to a collaborative team environment.

1. Specialty Processing (Developing Expertise). This work may include but is not limited to:

• • Resolves claims within an assigned single specialty area or process, including handling exceptions and non-routine scenarios.
  • Applies a foundational understanding of specialty work/lows, policies, and exception handling requirements.
  • Demonstrates the ability to independently resolve low to moderately complex issues within the assigned specialty.
  • Maintains adherence to quality, compliance, and performance standards within both general and specialty processing responsibilities.

1. Cross-Functional Communication and Issue Resolution. This work may include but is not limited to:
   • Responds to and manages inbound communications (e.g., emails, inquiries, and follow-ups) related to outstanding claims issues.
   • Collaborates with other departments to gather required information and drive timely claim resolution.
   • Performs outreach, as needed, to providers and members to clarify information and facilitate claim processing.
   • Ensures clear, accurate, and professional communication in all interactions to support effective issue resolution.

1. Operational Support and Rotational Responsibilities. This work includes but is not limited to:
   • Participates in rotational assignments, including daily operational tasks (“Dailies”), supporting overall work/low efficiency and continuity.
   • Completes assigned tasks with attention to detail and alignment to established processes and timelines.
   • Maintains accurate documentation of activities, outcomes, and follow-up actions.
   • Provides regular updates to leadership on progress, challenges, and resolution status.
   • Collaborates with internal teams to ensure timely and effective resolution of assigned work items.

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.
    • Demonstrated commitment to the company's core values of integrity, adaptability, service-focused, accountability, curiosity, and community.

Competencies

• • • Accountability
    • Coachability
    • Critical thinking