[Hiring] Government Programs Appeals and Grievances Research Specialist @Delta Dental Plan of Michigan, Inc.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description This role involves directing and assisting in the resolution of dental benefit determinations and analysis of provider and subscriber referrals, provider billing and treatment records analysis, and supporting the fraud & abuse program. • Researches, analyzes, and resolves cases for government programs members involving compliance issues including but not limited to balance billing, non-delivery of care, quality of care, personality disputes, anti-fraud hotline, internal referrals, and appeals. • Case research may include contract review and analysis, data analysis, records audit, and interviews with external customers. • Communicates to internal and external customers to obtain necessary information and relay actions taken and the resolution of cases. • Participates in an anti-fraud team responsible for identifying, preventing, and reporting fraud. • Prepares dental claims so appropriate determinations can be finalized with correct procedure policies and bypasses in place, adjudicates claims, analyzes documents, and maintains claims records. • Coordinates adjustments on difficult claims and inquiries. • Thoroughly documents case information within a case database for investigation, fraud, and/or legal cases. • Coordinates data to be used by internal or external parties including audits, hearings, and for use by legal counsel when necessary. • Participates in audits and hearings as necessary, including sample preparation and presentation. • Performs other related assigned duties as necessary to complete the Primary Job Responsibilities. Qualifications • Associate's degree in accounting, business administration, criminal justice, dental assisting or hygiene, or a related field. • Four years of experience in a position requiring knowledge of dental terminology, dental procedure codes, or dental office billing and record keeping practices. • Experience in administering dental benefit contracts within the insurance industry or identifying, analyzing, and resolving compliance issues based on policies and procedures outside of the insurance industry. • Previous experience supporting an anti-fraud/abuse program preferred. • Knowledge of word processing, spreadsheet, and database applications. • Strong verbal and written communication skills. • Strong analytical skills. • Ability to work independently and as part of a team. • Ability to manage multiple assignments with competing deadlines. • Ability to identify and resolve problems using independent judgment. Requirements • Equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance. Benefits • Comprehensive benefits package including medical, dental, and vision coverage. • Short- and long-term disability. • Life insurance. • 401(k) savings plans. • Flexible spending accounts. • Tuition reimbursement or educational assistance. • Annual incentive compensation based on annual business goals. • Eight hours of paid volunteer time each year. • Access to an on-staff health coach and personal trainer. • Many other perks. Apply tot his job