Dental Claims Examiner

HealthPlan Services is a leading managed health care services company, providing distribution, enrollment, billing and collection, claims administration, and risk services for health care payors and providers. HPS customers include insurance companies, HMOs and other managed care organizations, and organizations with self-funded health care plans. Based in Tampa, Florida, the company serves over 100,000 businesses, covering over 1.6 million members in the United States.

Job Title

Dental Claims Examiner

 

 

 

 Primary Function

(Weight 40%)

·  Responsible for processing and applying medical/dental and/or life claims benefits according to HPS and Carrier guidelines and policies.

·  Analyze and research claim issues

·  Adjudicate claims according to state and federal regulations, ERISA, HIPAA. 

·  Review and apply policy provisions 

·  Request and obtain necessary documents 

·  Release accurate benefits

·  Document required system information

·  Make outbound and take inbound calls 

·  Must read and comprehend certificate books

·  Handle 1st and 2nd Level escalated issues including questions & callbacks for management

·  Claims projects as assigned by management

·  Ability to train Level 1 associates

 

 

Minimum Education & Experience

·  HS or GED. 

·  2-5 years experience in related field

 

 

Expertise and Problem Solving Duties

·  Symptoms and facts may be incomplete, but the existence of a problem is apparent. 

·  Gaps must be filled by further inquiry, which is generally confined to related work areas.

·  Judgment is required to make decisions regarding planning, performing and sequencing operations within defined limits of recognized or standard methods or procedures. Decisions involving modifying or adapting existing methods to unique situations.

·  Fundamental principles must be applied to tasks, requiring creativity and ingenuity

 

 

 

Accountability and Supervision

·  Accountable for own work. 

·  Little supervision required.

·  Tasks which are generally informational, but which involve the incumbent in the analysis and/or decision-making resulting from the data itself. 

·  May also include tasks involved in the design and/or installation of the data-process itself.

·  Errors may not be obvious and may not be detected before substantial costs or time delays in the primary department activities were incurred

 

 

Job Knowledge

·  Basic general knowledge plus considerable administrative or creative knowledge of other functions or operations in order to develop new approaches to issues or problems. 

·  Usually achieved with experience through multiple business cycles in various assignments, generally 5-10 years. 

·  Effective job performance requires considerable experience.

 

 

Computer Operations

·  Computer literate.

·  Familiar with Microsoft Office.

 

HPS is a leading employer in the Tampa Bay Area. Our Tampa location is our company Headquarters, employing roughly 450 local employees, conveniently located in the Westshore Business District in Tampa, near Tampa International Airport. We offer an excellent benefits package including medical, dental, vision, 401K as well as free parking. Unfortunately, relocation assistance is not available for this position.