Claims Examiner I/II/III/IV (Dental)

Job Description:

Summary:

The Claims Examiner resolves a wide variety of claims transactions that may include, but not limited to, entry, adjudication or adjusting simple or complex claims in accordance with Member Touchpoint Measures (MTM), Inter-Plan Scorecard, FEP Performance Incentive Plan (PIP), Corporate Policies, National Committee of Quality Assurance (NCQA) and mandated requirements.

Essential Accountabilities:

Level I

• Handle front end transactions including but may not be limited to member eligibility, entry of claims, member & provider matching and claim processing.

• Identify patterns that impact quality, claim inventory, and/or the customer experience and escalate for review.

• Identify potential trends and if necessary, escalate for investigation/solution.

• In accordance with established departmental procedures, corporate policies, member, group, and provider contracts and riders:

o Process, enter, adjudicate and/or adjust and research claims.

o Request needed information through system generated letters and/or phone calls.

o Work closely with other required internal departments.

• Initiate and participate in learning opportunities around regulations, systems, procedures, and skills needed for the role.

• Consistently demonstrate professionalism, ability to be self-directed, have a high regard for quality output, attention to detail, and adherence to the desk level procedures and identify patterns that may impact the work.

• Collaborate and communicate effectively with internal/external customers to promote customer satisfaction.

• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.

• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.

• Regular and reliable attendance is expected and required.

• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Handle complex claim processing and/or limited adjustments.

• Identify trends, determine root cause, and recommend potential solutions.

• Engage in decision making processes to drive change.

• Identify, document, and effectively communicate risk to leadership.

• Efficiently resolve claims transactions, reference written policies and procedures and adhere to the most current business requirements.

• Assist other processors with questions and effectively sharing knowledge.

Level III (in addition to Level II Accountabilities)

• Handle high profile claim processing and all adjustments

• Identify, document, and effectively communicate risk to leadership and initiate action for resolution.

• Perform peer to peer training as needed.

• Initiate involvement for higher level responsibilities or proactively volunteers for assisting in the resolution of escalated issues.

Level IV (in addition to Level III Accountabilities)

• Ability to manage mass adjustment/scripting process, support analytical work as assigned and/or handle high profile adjustments.

• Provides expertise, mentoring, coaching, and guidance to peers.

• Independently identify, document, and effectively communicate risk to leadership, which includes a plan for strategic resolution on internal issues and those involving external exposure.

• Coordinate and effectively facilitate meetings at a peer level.

Minimum Qualifications:

NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels

• High School diploma or equivalent required.

• Relevant customer service or claims processing experience preferred

• Capacity to continuously develop skills necessary for growth.

• Basic computer required, including the ability to navigate in a Windows environment. Able to work between multiple programs and applications at the same time.

• Effective self-management including the ability to navigate in a Windows environment. Able to work between multiple programs and applications at the same time.

• Assigned tasks/duties performed under the guidance of a lead or supervisor.

• Adept at multi-tasking to efficiently resolve moderately complex claims processing and simple adjustment transactions.

• B Version: Valid NYS Independent Adjuster License and continued administrative maintenance of renewals is required.

Level II (in addition to Level I Qualifications)

• Minimum of one (1) year progressive experience in claims processing, customer service, or insurance related positions.

• Ability to analyze and resolve complex situations/transactions.

• Understanding of coordination of benefits (COB) determination.

• High skill level in reasoning and problem-solving.

• B Version: Valid NYS Independent Adjuster License and continued administrative maintenance of renewals is required.

Level III (in addition to Level II Qualifications)

• Minimum of three (3) years progressive experience in claims processing, customer service, or insurance related positions.

• Strong business acumen.

• Ability to work independently with a high level of accuracy.

• B Version: Valid NYS Independent Adjuster License and continued administrative maintenance of renewals is required.

Level IV (in addition to Level III Qualifications)

• Minimum of five (5) years progressive experience in claims processing, customer service, or insurance related positions

• Proven ability to serve as a mentor and coach for junior specialists.

• B Version: Valid NYS Independent Adjuster License and continued administrative maintenance of renewals is required.

Physical Requirements:

• The ability to hear, understand, and speak clearly while using a phone, with or without a headset.

• Ability to work while sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.

• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.

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In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

Level I: Grade N2: Minimum: $20.00 - Maximum: $24.43

Level II: Grade N3: Minimum: $20.40 - Maximum: $27.00

Level III: Grade N4: Minimum: $20.80 - Maximum: $30.80

Level IV: Grade N5: Minimum: $21.20 - Maximum: $33.03

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays. 

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.