Commercial Claim Administrator

Claim Administrators may specialize in one or more of DentaQuests business units and are responsible for the highest level of processing. Claim Administrators must use independent judgment and prior experience to accurately post refund checks, process complex follow ups that could not be resolved elsewhere, and adjust claims to a final resolution. Accuracy of 99% or higher is required.

PRIMARY JOB RESPONSIBILITIES:

• Consistently process advanced & complex claim adjustments with a 99% or greater accuracy rate .
• Uses business knowledge to independently resolve advanced claim adjustment scenarios including, but not limited to, refunds, corrections, follow ups, coordination of benefits, orthodontia, check returns, retention and all outstanding claim issues.
• Responsible for the adjustments to complex claims as necessary to meet corporate goals.
• Document work product and track outstanding items and turn around times within Windward or other manual tracking tools such as excel spreadsheets.
• Work closely with providers, members and clients to properly resolve claim issues.
• Collaborate with members of sales, client services and provider relations to address outstanding claim issues.
• Communicate with leadership on claim trends to assist in proactively resolving broader claim issues.
• Work with management to increase auto adjudication rates and self-service utilization.
• Process map workflow and lead resolution of ad hoc scenarios.
• May serve as back up to call center during peak periods by taking provider and member calls to ensure corporate wide service levels are consistently achieved.
• Serve as back up to Claim Research and Resolution team by researching and resolving claim issues
• Other duties as assigned.

JOB REQUIREMENTS:

• Associates degree and/or six years experience in a business environment.

• Strong math competency.

• Previous claim processing experience required.
• Attention to detail, accuracy and organization skills are essential.

• Understanding of general insurance principles.

• Independent and strategic decision making.
• Strong interpersonal, written and verbal communication skills.
• Self-motivation demonstrated by taking initiative to learn more and assume on more challenges.
• Cooperative, professional and effective interaction skills with co-workers, business partners and visitors.

• Ability to work in excess of 40 hours in a week.
• Ability to efficiently operate computer.
• Ability to use Microsoft Office. (Word, Excel and Outlook)
• Able to follow verbal and written instructions.
• Ability to read and comprehend at a high school level.
• Ability to communicate in an active office environment.
• Ability to sit for more than 90% of an 8 hour day.

• Ability to use basic office equipment and communicate via telephone or computer technology, by way of written and verbal channels.

PHYSICAL DEMANDS:

• Ability to communicate in an active office environment.
• Ability to efficiently operate all job-related office equipment.
• Ability to communicate via telephone.
• Ability to sit for 80% or more of an 8-hour workday.
• Ability to read and view a computer screen.
• The office environment is active with high voice levels and interruptions that may challenge hearing and concentration.