Resolution and Research Processor - DentaQuest - Grafton, WI

Claim Resolution and Research processors will specialize in one or more of DentaQuest’s business units and are responsible for the highest level of problem solving. Claim R&R must use independent judgment and prior experience to accurately research complex payment and processing scenarios and apply existing and new solutions to close claim and payment inquiries. Accuracy of 99% or higher is required.

JOB DUTIES AND RESPONSIBILITIES:
Consistently research and resolve advanced & complex payment and adjustment scenarios with 99% or greater accuracy

Work closely with providers, members and clients to properly resolve claim issues.

Visit provider offices and work with staff to resolve disputes over complex claim payment scenarios

Exhibit strong knowledge of business protocols and recommend unique solutions to complex scenarios

Understands and assist with payment processes to ensure accurate & timely payment of claims

Uses business knowledge to independently resolve advanced claim adjustment scenarios including, but not limited to, refunds, corrections, follow ups, COB (coordination of benefits), ORTHO (orthodontia), and all outstanding claim issues.

Works with unsatisfied customers to resolve payment inquiries.

Responsible for the adjustments to complex claims as necessary to meet corporate goals

Document work product and track outstanding items and turnaround times within Windward or other manual tracking tools such as excel spreadsheets.

Work closely with providers, members and clients to properly resolve claim issues.

Collaborate with members of sales, client services, and provider relations to address outstanding claim issues.

Communicate with leadership on repetitive issues assisting in proactively resolving claim issues

Work with management to increase auto adjudication rates and self service utilization

Process map workflow and lead resolution to ad hoc scenarios

May serve as back up to call center during peak periods to ensure corporate wide service levels are met

Serve as back up to claim administration by adjusting claims, posting refund checks and/or processing follow ups.

Perform other duties as requested. Exceptionally strong interpersonal, written and verbal communication skills.

Attention to detail, accuracy and organization skills is essential.

Independent and strategic decision making.

Demonstrates self-motivation by taking initiative to learn more and take on more challenges.

Cooperative, professional and effective interaction skills with co-workers, company staff and visitors.

Ability to use basic office equipment and communicate via phone, computer technology, and via written and verbal channels.

Excellent math competency.

Understanding of general insurance principles.

Ability to use Microsoft Office (Word, Excel, Outlook).

Able to follow verbal and written instructions.

Ability to read and comprehend at a high school level.

Ability to communicate in an active office environment Associates degree and/or six years experience in a business environment.

Previous claim processing experience required.

Ability to work in excess of 40 hours in a week