Operations Specialist Position Available In Providence, Rhode Island

Operations Specialist 3.6 3.6 out of 5 stars 10 Charles Street, Providence, RI 02904

Position Summary:

The Operations Support Specialist primary responsibilities will be to work independently to process all claims, including claims of high complexity. This role will be matrixed between the Operation’s and Dental Case Management teams. Operationally, the position will be asked to research and investigate claim issues and bring to completion. From a DCM perspective, this team member will review and process claims based off Utilization review guidelines.

Essential Duties:

(include but are not limited to) Monitor and process daily incoming claim records that suspend for further research. Understand and process claims with Coordination of Benefits. Utilize a thorough understanding of claims processing to research and adjust claims as required. Maintain 99.95% claims financial accuracy. Work in a self-starting manner to resolve issues as they arise. Alert management of claims related issues in a timely manner. Collaborate with Management to help determine efficiencies in process. Review quality of other analysts claims to ensure proper processing. Assist with other Operational department functions as needed. Conducts the first level of clinical review for claims involving prosthetics, periodontics, oral surgery, implants, etc.; meeting production standards established for the position. Refer those claims having a questionable determination to a Dental Consultant, with supporting documentation and a recommended decision. Approve and adjudicate claims using judgments based on clinical experience, precedent, and company dental policy. Provide clear and concise documentation of clinical assessment in our claims system to thoroughly meet internal/external requirements. Communicate with a dentist’s office when further information is necessary to render a decision on a claim.

Qualifications:

(Education/Experience/Skills Required) High school diploma Minimum 2-4 years of experience in the dental/insurance industry 2-4 years operational experience with complex regulated products and client base Knowledge of claims processing Ability to read dental radiographs Problem solving skills Excellent written and verbal communications and presentation skills Proficient desktop computer skills, advanced Excel and data query skills Work Environment /

Physical Demands:

Typical office environment

Attendance Requirements:

40-hour workweek (M-F) as assigned and additional hours as required.