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Dental Claims Analyst

Company: PacificSource Health Plans
Location: Eugene
Posted on: February 15, 2019

Job Description:

Accurately process dental claims for Commercial and self-funded clients according to all policy provisions and department policies and procedures. Review and research dental claims and determine coverage based on contract, provider status and claims processing guidelines. Provide subject matter expert (SME) level support to internal staff.

  • Work in assigned dental claims processing Workflow roles. Review plan benefits and determine coverage based on contract and claims processing guidelines. Verify accuracy of information entered or imaged.
  • Review pre-treatment estimates to ensure accurate entry and processing.
  • Identify and direct appropriate claims for Dental Director review.
  • Document decisions using notes system to record pertinent information.
  • Return radiographs to dental provider once review is completed.
  • Update Coordination of Benefits (COB) records on members when necessary.
  • Provide subject matter expert (SME) level support to internal customers and answer questions regarding dental claims processing, terminology and benefits.
  • Request additional information or clarification needed to process claims or dental pre-determinations as needed.
  • Identify dental issues that affect other PacificSource departments, and advise appropriate internal personnel of claim processing concerns and/or problems
  • Assist in the development and maintenance of the Dental Claims Processing Manual and other dental related department policies and procedures. Supporting Responsibilities:
    • Meet department and company performance, accuracy and attendance expectations.
    • Actively participate in the Dental Claims Workgroup or other committees/workgroups as assigned.
    • Regularly attend team meetings and daily team Visual Board huddle.
    • Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    • Perform other duties as assigned. Work Experience: One year of dental insurance, dental biling or dental office experience is required. Education, Certificates, Licenses: Requires high school diploma or equivalent. Knowledge: Must have working knowledge of dental terminology and CDT dental coding as well as a thorough understanding of dental plan designs, provider/network relationships and health insurance terminology. Ability to read and understand health contracts, insurance terminology, benefit language, Explanation of Benefits documentation, COB rules and medical claim forms required. Preferred computer skills include keyboarding and 10-key proficiency, basic Microsoft Word and Excel. Ability to prioritize work and perform under time constraints. Team player willing to collaborate and help others accomplish team objectives. A fundamental understanding of self-insured business is helpful. Ability to work independently and make decisions within prescribed guidelines. Competencies Our Values
      • Building Customer Loyalty
      • Building Strategic Work Relationships
      • Continuous Improvement
      • Adaptability
      • Building Trust
      • Work Standards
      • Contributing to Team Success
      • Planning and Organizing
        • We are committed to doing the right thing.
        • We are one team working toward a common goal.
        • We are each responsible for our customers' experience.
        • We practice open communication at all levels of the company to foster individual, team and company growth.
        • We actively participate in efforts to improve our communities-internal and external.
        • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence. Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time. Physical Requirements:Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively. Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times. PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

          Keywords: PacificSource Health Plans, Eugene , Dental Claims Analyst, Professions , Eugene, Oregon

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