Senior Dental Benefits Specialist

This is a fully remote position, open to applicants in Kansas.

📋 Description

• Ensure that second-level appeal documentation is precise, comprehensive, defensible, and aligns with plan provisions, benefit policies, and clinical appropriateness criteria.

• Independently assess documentation sufficiency, the necessity for additional clinical reviews, and whether case records substantiate final decisions.

• Manage the complete clinical review process between G.E.H.A.'s TPA and the clinical review vendor.

• Compile well-organized case summaries and supporting documentation to facilitate timely determinations.

• Monitor appeal status, analyze rationale, and evaluate outcomes in accordance with established turnaround standards.

• Review determination letters and correspondence for accuracy and completeness.

• Maintain organized and audit-ready appeal case files.

• Identify trends in appeal volume, denial reasons, and determination outcomes for the Manager of Dental Product.

• Act as an escalation point for complex or disputed appeal documentation inquiries.

• Conduct random and directed post-payment claims audits.

• Evaluate paid dental claims against plan provisions, CDT coding standards, and benefit limitations.

• Detect overpayments, billing errors, coding inconsistencies, and potentially improper payments.

• Prepare clear audit findings reports that include irregularity details, monetary amounts, and supporting rationale.

• Maintain audit records and tracking logs.

• Identify systemic billing trends and recurring coding issues.

• Determine the scope and sampling approach for directed audits.

• Serve as G.E.H.A.'s internal dental subject matter expert on benefit interpretation, CDT coding, claim adjudication logic, and plan provisions.

• Assist with benefit policy interpretation, OPM filings, benefit design reviews, member escalations, and dental-specific evaluations.

• Provide guidance to internal partners and TPA staff regarding dental benefit provisions and CDT coding standards.

• Review member-facing dental educational content for clinical and benefit accuracy.

• Assist in updating educational materials to align with clinical guidelines, plan provisions, regulatory requirements, and communication standards.

⛳️ Requirements

• Associate's or Bachelor's degree in Dental Hygiene, Health Administration, or a related clinical or health field is preferred.

• Additional years of relevant work experience may be considered in place of formal education.

• Strong preference for dental clinical training, certification, or licensure (RDH or equivalent); equivalent applied dental clinical knowledge from extensive dental claims, appeals, or utilization review practice will be considered.

• A minimum of 5 years of experience in dental claims review, dental benefits administration, or dental appeals processing within a health plan or managed care setting.

• Proven independent ownership of appeal documentation, clinical review coordination, or claims audit responsibilities.

• Advanced expertise in dental benefit administration, CDT coding, dental claims adjudication, coordination of benefits, dental benefit structures, and common billing practices.

• Required direct experience in supporting appeal documentation, coordinating clinical reviews, or performing claim audits in a dental insurance or managed dental care environment.

• Ability to independently assess coding accuracy, benefit application, claim adjudication logic, and payment appropriateness in complex dental claims and appeal situations.

• Capacity to exercise independent judgment and work without routine supervision.

• Ability to clearly communicate benefit, coding, and adjudication reasoning to non-dental colleagues and external partners.

• Strong analytical and clinical reasoning skills.

• Excellent written communication capabilities.

• Exceptional attention to detail and a quality-first mindset.

• Organized and deadline-oriented, capable of managing multiple concurrent appeals and audit assignments.

• Ability to collaborate effectively with cross-functional partners, the TPA, and the clinical review vendor.

• Proficiency in Microsoft Office Suite.

• Familiarity with FEDVIP, FEHB, or federally regulated dental benefit programs is a plus.

• Experience in applying clinical appropriateness criteria or benefit plan provisions is preferred.

• Experience in reviewing written determination letters or preparing audit findings reports is preferred.

• Strong preference for experience serving as a dental subject matter resource or direct engagement with a TPA or clinical review vendor.

• Must provide non-cellular high-speed internet service such as fiber, DSL, or cable modem for a home office.

• Minimum internet speed of 30 Mbps download and 5 Mbps upload required.

• Latency response time must be lower than 80 ms.

• Hotspots, satellite, and wireless internet services are not permitted.

• A dedicated workspace is essential to avoid ongoing interruptions to protect member PHI/HIPAA information.

🏝️ Benefits

• Competitive pay/salary ranges.

• Incentive plan.

• Health/Vision/Dental benefits effective from day one.

• 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) along with a 6% annual company contribution.

• Comprehensive employee well-being program.

• Paid Time Off.

• Personal Community Enrichment Time.

• Company-provided Basic Life and AD&D insurance.

• Company-provided Short-Term & Long-Term Disability coverage.

• Tuition Assistance Program.

• Opportunity for remote work.

• Hybrid and work-from-home options available for many roles.