Medical or Dental Claims and Preauthorization Representative
We are looking for a Claims Analyst for a Utilization Management Representative role.
Location: Coral Gables, 33134
Shifts: Monday – Friday 8:30am – 5:30 pm
Bilingual: Required (English and Spanish)
Experience: Medical or Dental Claims Experience required
This company provides managed care dental services to HMOs, Discount Medical Plans, Medicare Advantage Plans, employers and individuals. We are focused solely on providing quality dental benefits. For us, ancillary benefits are our top priority, not a secondary product offering. We have recently acquired several large contracts providing an exciting opportunity for job opportunities and growth within the organization.
Responsible for actively participating in the daily dental claims and preauthorization activities. Ensures that dental services are provided within the context of the member benefit coverage and that services are provided in a timely, high quality and cost-effective manner.
• Respond to request for preauthorization of services submitted via mail, phone, fax or electronically.
• Verify eligibility and benefits.
• Use professional business communication to conduct outreach to dental offices for necessary information required for claims/preauthorization processing.
• Prepare information for pre-authorizations that require clinical review for medical appropriateness by the Dental Director.
• Assist the Dental Director as a resource for benefits and questions related to coverage and/or utilization review guidelines.
• Identify potential quality of care issues and notify the Claims Manager/Dental Director.
• Ensure claims/preauthorization are processed within the established timeframes.
• Maintain 98% accuracy for processing of dental claims and preauthorizations.
• Run reports for claims and preauthorization processing times.
• Collaborate with department to review plan business rules prior to adjudication and ensure implementation is accurate.
• Enter accurate claims information into company systems.
• Enter and adjudicate claims, prior authorizations and adjustments.
• Print and mail letters, explanation of payments and approval/denial letters to members and dental offices.
• Customer service efficacy to communicate coverage decisions based on the Dental Director’s determination and claims/preauthorization business rules.
• Assist in monthly audits of claims entry accuracy
• High School Diploma/GED
• Data Entry
• Detail oriented
• Dental billing and coding knowledge (preferred)
• Experience with account audit coordination and reconciliation
• Excellent written, verbal and communication skills.
• Strong analytic and problem solving abilities.
• Ability to use Microsoft Word, Excel, PowerPoint, and other business tools.