[Hiring] Special Investigations Unit Claims Specialist @Delta Dental of Michigan

Role Description

To analyze and adjudicate dental claims for possible fraud or aberrant treatment behavior patterns.

• Prepares Focused Review dental claims so appropriate determinations can be finalized with correct procedure policies and bypasses in place.
• Adjudicates claims, analyzes documents, maintains claims records, and coordinates adjustments on difficult claims and inquiries.
• Identifies and investigates aberrant treatment behavior patterns, and conducts continuous investigation when needed.
• Conducts determinations and clarifies questionable treatment patterns with dental consultant, and records all consultant determinations in the Claims System.
• Investigates claim reconsiderations, inquiries, and adjustments and prepares claims for a second and/or third opinion when necessary.
• Provides dental expertise and/or interpretations of dental policies, procedure codes, and processing guidelines to internal and external contacts.
• Performs other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

Qualifications

• Associate's degree, technical, vocational, or business school with coursework relating to dentistry.
• Two years' experience in chair side assisting.
• Advanced knowledge of dental terminology and dental procedures.
• Ability to read and interpret radiographs, electronic images, and photos.
• Experience working with word processing and spreadsheet software.
• Effective verbal and written communication skills.
• Ability to resolve moderately complex problems and use independent judgment.
• Experience with Provider system; ETS; Client and Provider contracts are preferred.

Requirements

• Must reside in Michigan within a reasonable commuting distance of our Okemos, MI office for team meetings, collaborative sessions, and training.

Benefits

• Equal employment and advancement opportunity within the context of its unique business environment.
• Non-discrimination based on race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.