Special Investigations Unit Claims Specialist

Job Title:

Special Investigations Unit Claims Specialist

Number of Positions:

2

Location:

DDMI_Michigan

Location Specifics:

Fully Remote

Job Summary:

Candidates must reside in Michigan within a reasonable commuting distance of our Okemos, MI office for team meetings, collaborative sessions, and training.

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation.

At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do – from taking charge of our careers, to helping colleagues and lending a hand in the community.

Position Description:

To analyze and adjudicate dental claims for possible fraud or aberrant treatment behavior patterns. 

Primary Job Responsibilities:

• Prepares Focused Review dental claims so appropriate determinations can be finalized with correct procedure policies and bypasses in place.  

• Adjudicates claims, analyzes documents, maintains claims records, and coordinates adjustments on difficult claims and inquiries.

• Identifies and investigates aberrant treatment behavior patterns, and conducts continuous investigation when needed.

• Conducts determinations and clarifies questionable treatment patterns with dental consultant, and records all consultant determinations in the Claims System. 

• Investigates claim reconsiderations, inquiries, and adjustments and prepares claims for a second and/or third opinion when necessary.

• Provides dental expertise and/or interpretations of dental policies, procedure codes, and processing guidelines to internal and external contacts.

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

#LI-Remote

Minimum Requirements:

Position requires an associate's degree, technical, vocational, or business school with coursework relating to dentistry and two years' experience in chair side assisting. Will accept any suitable combination of education, training, or experience.

Position requires advanced knowledge of dental terminology and dental procedures and the ability to read and interpret radiographs, electronic images and photos; experience working with word processing, and spreadsheet software; effective verbal and written communication skills; ability to resolve moderately complex problems and use independent judgment; experience with Provider system; ETS; Client and Provider contracts are preferred.

The company will provide equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.