Company Statement
Connecticare is a leading health plan in the state of Connecticut and a subsidiary of EmblemHealth, a health and wellness company that provides insurance plans, primary and specialty care, and wellness solutions. WellSpark is a digital wellness company and national subsidiary of EmblemHealth that offers a full suite of products and solutions to reward people for healthy behaviors.
Dental Claims Review Analyst
Job Summary
Analyze, review, and process suspended claims, predetermination, and Service Requests based on industry standards and
clinical guidelines. Research, analyze, and investigate member benefits, policy and procedures for claims, grievance and appeal cases. Provide provider outreach where necessary to facilitate claim resolution and escalated service requests. Obtain claim records and supporting documentation needed for resolution. Collaborate with Dental Consultants to review and triage escalated claims, pre-determinations, and service requests. Integrate clinical expertise with industry knowledge to identify potential fraud patterns upon claim submission, alerting
dental director, and SIU team when applicable.
Responsibilities
• Review and analyze claims and pre-determinations within suspended system inventory using clinical expertise, industry standard guidelines, and benefit policy and procedures and make changes to procedure codes when necessary, using-supporting documentation (including radiographs, charting, correspondence) for payment or denial.
• Perform provider outreach when applicable for resolution.
• Investigate member benefits, policy and procedures for claims, grievance and appeal cases, and member and provider outreach via customer service and dental network team.
• Utilize specialized knowledge to analyze and resolve issues with dental claim coding.
• Initiate down-coding of submitted procedure codes that do not meet standards of care and/or the supporting documentation submitted with claim. Refer clinical denials to consultant for review with all necessary support information when needed.
• Identify potential claims problems or fraud patterns and refer to Lead analyst, Dental Director and SIU when necessary.
• Identify the need for new messages to clarify the Explanation of Benefits; contribute to/develop message changes.
• Recommend methods to improve the dental logic to boost system efficiency to Dental Director.
Qualifications
• Bachelor’s Degree.
• Certification as Dental Hygienist or Claims Coding Required
• 2 –3+ years of related experience, including experience in a clinical dental environment Required
• Additional experience/specialized training/certifications may be considered in lieu of Bachelor’s degree Required
• Knowledge of claim processing policies and procedures Required
• Proficient with MS Office - Word, Excel, PowerPoint, Outlook, Teams, etc. Required
• Strong communication skills - verbal, written, presentation, interpersonal Required
• Demonstrated analytical and problem-solving skills Required
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.