Claims Review Specialist

This is a temporary, part-time position with an expectation of 24 hours per week. 

Key Responsibilities:

• Review and analyze claim data of dental service providers who participate in Delta Dental networks in order to determine the propriety of claims submission by dentists and claims payment by Delta Dental of Colorado.
• At the direction of Internal Audit, performs in-depth claim processing audits, including the use of data extraction and analysis techniques.
• Identify familiar indicators of various types of fraud, waste, and abuse among dental service providers.
• Compare and contrast claims data mined from dental service providers with benchmarks for procedures regularly performed by the providers’ cohorts.
• Utilize metrics, analytical tools, and dental knowledge to detect potentially fraudulent, wasteful, or abusive patterns of practice by dental service providers participating in Delta Dental networks.
• Review claims data and aggregate such data for presentation to Compliance staff and Senior Leadership Team in readily understandable form.
• Identify dental service providers whose practice patterns diverge in a material way from the benchmarks established for the providers’ cohorts and analyze whether such divergence is the result of fraud, waste, abuse, or some other circumstance. Report findings to Delta Dental supervisor and be prepared to submit external reporting upon any suspected fraud or abuse.
• Utilize Delta Dental’s analytic software to create data queries as necessary.
• Prepare reports on audit activity and create ad hoc reports as necessary.
• As necessary, investigate, research and make determinations on member appeals and provider disputes based on contract language, expert professional opinion, benefit interpretation, regulatory interpretation, member communications and understanding of all systems used to provide and authorize service or payment.
• Work with Internal Audit personnel to understand claim processing errors.
• Other duties and projects as assigned.

Qualifications:

• Associate degree or equivalent experience in business administration, health care administration, auditing, accounting, or related field.
• Minimum of five (5) years’ background in dental practice management and/or dental service provision (i.e. Dental practice manager, Expanded Duty Dental Assistant or Dental Hygiene background).
• Solid understanding of dental insurance industry regulations, statutes and procedures.
• Solid understanding of Delta Dental’s policies, procedures and regulations governing participating dentists.
• Knowledge of spreadsheet and database applications.
• Demonstrated conflict resolution and mediation skills with ability to secure action.
• Excellent organization, planning, and analytical, skills required.
• Excellent inter-personal relations, written and verbal communication skills with the ability to effectively communicate and interact with all levels of personnel.

Scope of Authority:

Defined procedures cover most duties. Generally expected to deal with different and specialized situations in assigned job.  Delta Dental Participating Dentist Agreements, DDPA Processing Policies, Delta Dental Internal Processing Guidelines, Delta Dental Dentist Handbook and Policy Statements, as well as Delta Dental’s Policies & Procedures are utilized as reference tools.

Authority to determine and collect monies owed to Delta Dental and to Delta Dental members. Errors in calculations impact dentists and members and results in rework and damage to Delta Dental’s reputation.

Plans daily work activities and prioritizes tasks.

Working Conditions:

• Regular and reliable attendance is required.  
• The noise level in the work environment is usually minimal.  
• Regular exposure to a computer screen. Requires use of standard office equipment, e.g., Computer, scanner, printer, telephone. 
• While performing the duties of this job, the employee is regularly required to walk, stand, talk or hear. The team member frequently uses hands to type, touch, grasp, or hold; reach with hands and arms. 
• Ability to perform the essential functions of the job with or without a reasonable accommodation. 
• Working hours are consistent with normal business operating hours (8:00am – 4.30pm).

This is a temporary, part-time position with an expectation of 24 hours per week. 

Compensation range: $22.71-$29.99 per hour. 

Salary : $23 - $30