Dental Claims Resolution Specialist

BDR Solutions, LLC, (BDR) supports the U.S. Federal Government in successfully achieving its mission and goals. Our service and solution delivery starts with understanding each client’s end-state, and then seamlessly integrating within each Agency’s organization to improve and enhance business and technical operations and deployments.

BDR is seeking a Dental Claims Resolution Specialist to join our growing team! This position will be performed virtually from the individual’s home office working on EST time schedule. This position requires US Citizenship with a Public Trust or the ability to obtain one.   

(Military Veterans and HUBZone candidates are highly encouraged to apply)

Role Overview:

The Dental Claims Resolution Specialist is responsible for investigating, recovering and resolving all types of claims. Educate and inform members and providers of program coverage and limitations for claims within contract requirements. Use critical thinking, research and problem-solving skills to navigate through the complexities of a member's health benefits and their respective claims while remaining within the program guidelines.

Responsibilities:

• Maintain an ongoing responsibility for assigned claims inquiries which entails assessment, education and coordination for members/health care providers while keeping a detailed record within the internal database.
• Establish and maintain positive relationships with members, providers and our claims contractor.
• Demonstrates great depth of knowledge/skills in own function.
• Request and manage medical records to help determine potential program coverage and communicate results to the members.
• Completion of system generated tasks, including documenting all results as required.
• Prepare comprehensive reviews and summaries for claim appeals.
• Point of contact for internal departments to answer questions relative to member claims.
• Work with internal department to request code additions or other avenues to resolve issues in the program where appropriate.
• Understand the claim lifecycle and ensure that claims are resolved through the entire process.
• Solves moderately complex problems on own.
• Proactively identifies solutions to non-standard requests/inquiries.
• Work with the leadership team to resolve complex issues as needed.
• Able to handle emotionally charged phone calls and ability to deliver unfavorable claim outcomes.
• Ability to communicate complex program criteria into easily understood summaries in both oral and written communication.
• Validation of claim coverage in relation to program guidelines.
• Plans, prioritizes, organizes and completes work to meet established objectives and metrics.
• Complete activities and reporting as required by the fraud, waste and abuse plan.
• Monitor progress of Accounts Receivable targets and plans within contract KPI's (reword to remove A/R)?.
• Performs periodic and month-end balancing and reporting activities.
• Perform research/verification of identified claims to identify payment/overpayment issues/accuracy.
• Work with payers/providers to review claim information and identify issues related to payment accuracy.
• Document and communicate outcomes of claims investigations/overpayment reviews to applicable stakeholders.

Required Minimum Qualifications:

• Minimum of three years of claims processing or similar experience.
• Equivalent combination of education, experience and/or applicable military experience will be considered.
• Proficient computer skills with Microsoft Office Suite experience.
• Ability to work independently as well as on a team.
• Excellent verbal and written communication skills including strong telephone etiquette and interpersonal skills with individuals at all levels of an organization.
• Demonstrated ability to adapt to performing a variety of duties, changing from one task to another of a different nature, without a loss of efficiency or composure.
• Must be able to implement critical thinking and decision making skills in order to identify appropriate care/treatment plans for a wide range of members from low to high complexity.
• Must have the ability to take initiative and be detail-oriented in a goal-orientated environment.

Preferred Qualifications:

• Associate's Degree in Business Administration or related field.
• Medical Coding, Registered Health Information Technician (RHIT) or equivalent.
• Medical call center experience or medical related experience in a corporate/business setting.
• Certified Medical Reimbursement Specialist CMRS exam completion.
• National Career Readiness Certificate.
• Dental claims processing experience.

In addition, U.S Citizenship is required. Select applicants will be subject to a government security investigation and must meet eligibility requirements for access to classified information and be able to obtain a government-granted security clearance. Individuals may also be subject to a background investigation including, but not limited to criminal history, employment and education verification, drug testing, and creditworthiness.

BDR is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, marital status, disability, veteran status, sexual orientation, or genetic information. 

Requirements