Research & Resolution Specialist (Remote)
Location: Remote, Connecticut US
Job Number: 899
Claim Research and Resolution Specialists may specialize in one or more of DentaQuest's business units and performs a high level of problem solving. Claim R&R must use independent judgment and prior experience to accurately research complex payment and processing scenarios and apply existing and new solutions to close claim and payment inquiries. Accuracy of 99% or higher is required.
PRIMARY JOB RESPONSIBILITIES: Consistently research and resolve advanced & complex payment and adjustment scenarios with 99% or greater accuracy Work closely with providers, members and clients to properly resolve claim issues Communicate with provider offices and work with staff to resolve disputes over complex claim payment scenarios Exhibit strong knowledge of business protocols and recommend unique solutions to complex scenarios Understand and assist with payment processes to ensure accurate & timely payment of claims Uses business knowledge to independently resolve advanced claim adjustment scenarios including, but not limited to, refunds, corrections, follow ups, coordination of benefits, orthodontia and all outstanding claim issues May work with unsatisfied customers to resolve payment inquiries Provides adjustments to complex claims as necessary to meet corporate goals Document work product and track outstanding items and turnaround times within Windward or other manual tracking tools such as excel spreadsheets Collaborate with members of sales, client services and provider relations to address outstanding claim concerns Communicate with leadership on processing trends and assist in proactively resolving broader claim challenges Research, analyze, resolve and respond to any internal and external inquires Work with management to increase auto adjudication rates Process map workflow and lead resolution to ad hoc scenarios May serve as back up to call center during peak periods to achieve corporate wide service levels Serve as back up to Claim Administration team by adjusting claims, posting refund checks and/or processing follow ups Other duties as needed or required.
- Associates degree required
- Four years of experience in a business environment.
- Excellent math competency
- Previous claim processing experience required
- Exceptionally strong interpersonal, written and verbal communication skills
- Attention to detail, accuracy and organization skills are essential Understanding of general insurance principles
- Independent and strategic decision making
- Self-motivation demonstrated by taking initiative to learn more and assume more challenges
- Cooperative, professional and effective interaction skills with co-workers, business partners and visitors
- Experienced in Microsoft Office (Word, Excel and Outlook)
- Effective use of office equipment including, but not limited to, computers and printers
- Able to follow verbal and written instructions
- Ability to read and comprehend at a post high school level
- Ability to communicate in an active office environment
- Ability to use basic office equipment and communicate via phone, computer technology, and via written and verbal channels
- Required to attend additional training as requested/deemed necessary.
- Bachelor's degree preferred.
- Experience working in the insurance industry a plus.
PHYSICAL DEMANDS: Incumbent must be able to communicate effectively. Requires overall light physical effort (up to 25lbs.) Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer). Ability to travel or move about within and outside serviced facilities required. Incumbent works primarily in either a private or shared office environment
At DentaQuest, we believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system - from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.
Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it.
To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and deliveringmeasurableoutcomes for the people we serve.
The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.
Job Number: 2922
Community / Marketing Title: Research & Resolution Specialist (Remote)
Location_formattedLocationLong: Remote, Connecticut US