[Hiring] Senior Dental Benefits Specialist @GEHA Health

Role Description

The Senior Dental Benefits Specialist is responsible for second-level appeal documentation integrity, clinical review coordination between G.E.H.A's third-party administrator (TPA) and clinical review vendor, and post-payment claims audits for G.E.H.A's dental programs. This role serves as G.E.H.A's internal dental subject matter expert for benefit interpretation, CDT coding, claims accuracy, and appeal documentation defensibility.

Operating as a senior individual contributor within a federally regulated dental benefits program, the Specialist independently determines documentation sufficiency, identifies when additional clinical review or policy interpretation is required, defines the scope of directed claim reviews, and prepares defensible appeal and audit findings without routine review.

The role ensures appeal files, determination records, and audit findings are complete, objective, and audit-ready for internal review, OPM review, or federal audit.

Qualifications

• Associate's or Bachelor's degree in Dental Hygiene, Health Administration, or a related clinical or health field preferred.
• Additional years of qualifying relevant work experience may be considered in lieu of formal education.
• Dental clinical training, certification, or licensure (RDH or equivalent) strongly preferred; equivalent applied dental clinical knowledge gained through sustained dental claims, appeals, or utilization review practice will be considered.
• Requires a minimum of 5 years of experience in dental claims review, dental benefits administration, or dental appeals processing in a health plan or managed care environment.
• Advanced working expertise in dental benefit administration, CDT coding, dental claims adjudication, coordination of benefits, dental benefit structures, and common billing practices.
• Direct experience supporting appeal documentation, coordinating clinical reviews, or conducting claim audits in a dental insurance or managed dental care setting required.
• Credible as a dental subject matter resource; able to explain benefit, coding, and adjudication reasoning clearly to non-dental colleagues and external partners.
• Excellent written communication skills.
• Meticulous attention to detail with a quality-first approach.
• Organized and deadline-driven.
• Collaborative and professional.
• Proficiency in Microsoft Office Suite; experience with claims review systems or case management tools preferred.

Requirements

• Conduct post-payment claims audits on a random basis and as directed.
• Prepare audit findings reports that are complete, clearly written, and sufficient for appropriate operational follow-up.
• Maintain audit records and tracking logs that document scope, findings, and disposition of each audit.
• Identify systemic billing patterns or recurring coding issues across audit samples.
• Determine audit scope and sampling approach for directed reviews.
• Review member-facing dental education content for clinical and benefit accuracy.
• Assist with reviewing and updating educational materials to ensure alignment with current clinical guidelines.

Benefits

• Competitive pay/salary ranges.
• Incentive plan.
• Health/Vision/Dental benefits effective day one.
• 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution.
• Robust employee well-being program.
• Paid Time Off.
• Personal Community Enrichment Time.
• Company-provided Basic Life and AD&D.
• Company-provided Short-Term & Long-Term Disability.
• Tuition Assistance Program.