The incumbent in this position is responsible for the review and final
adjudication of claims and re-evaluation requests that require professional
·Processes claims and re-evaluation requests.
·Identifies the prognosis of submitted services and approves/denies based on
·Returns provider’s calls to discuss denials, policies and contractual
·Reviews and analyzes documentation related to patient complaints.
·Prepares draft responses to internal staff pertaining to enrollee and provider
grievances and appeals.
·Provides assistance to Managing Dental Consultants and Legal department in
·Requests refunds from providers.
·Performs miscellaneous duties as assigned.
·A DDS or DMS degree from an accredited dental school.
·A minimum of 5 years of private practice dentistry.
·2 or more years of training, processing and policy experience.
·Active and unencumbered license.
·Good standing with the Dental Licensing Board of the appropriate state.
·Strong organizational/time management skills and multi-tasking abilities.
·Detail oriented with analytic and problem-solving abilities.
·Customer service, conflict management and dispute resolution skills.
·Knowledge and application of English grammar, composition, editing and
·Knowledge of health care industry issues preferred.
·Knowledge of Delta Dental products, policies, claims, eligibility and