Claims Processing Representative 2

The Claims Processing Representative 2 determines whether to return, deny, or pay claims following organizational policies and procedures. Decisions are typically focus on interpretation of area/department policy and methods for completing assignments. Works within defined parameters to identify work expectations and quality standards, but has some latitude over prioritization/timing, and works under minimal direction. Follows standard policies/practices that allow for some opportunity for interpretation/deviation and/or independent discretion.

The Claims Processing Representative 2 reviews and adjudicates complex or specialty claims, submitted either via paper or electronically. The Claims Processing Representative 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.

The Claims Processing Representative 2 determines whether to return, deny, or pay claims following organizational policies and procedures. Decisions are typically focus on interpretation of area/department policy and methods for completing assignments. Works within defined parameters to identify work expectations and quality standards, but has some latitude over prioritization/timing, and works under minimal direction. Follows standard policies/practices that allow for some opportunity for interpretation/deviation and/or independent discretion.

The Dental Claims Processing Representative 2 is responsible for reviewing, adjudicating, and making determinations on complex and specialty claims, received either on paper or electronically, in accordance with organizational policies and procedures. This is a production-focused role with clearly defined quality and productivity metrics that must be met. The representative interprets departmental policies to decide whether claims should be returned, denied, or paid, and performs a variety of moderately complex administrative, operational, and customer support activities, including calculations and semi-routine tasks.

Working within defined parameters, the Dental Claims Processing Representative 2 exercises some discretion in prioritizing and timing assignments, operating under minimal direction. While standard policies and practices guide most decisions, there is opportunity for interpretation and independent judgment to ensure accuracy and compliance. Consistent achievement of high-quality outcomes is expected in alignment with client values and performance standards.

Required Qualifications

Less than 3 years of technical experience

Proficiency in all Microsoft Office: Word, PowerPoint, Excel, and Access

CAS Claims processing experience

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Required Qualifications

• High school diploma or GED equivalent

• Demonstrated strong attention to detail

• Effective written and verbal communication skills

• Strong analytical and problem-solving abilities

• Proficiency in Microsoft Office applications, including Word and Excel

• 1–2 years of relevant technical experience

Preferred Qualifications

Bachelor's Degree
Quality background
Prior Billing and Enrollment experience for MTV
CPU (CMS Processing Unit) case knowledge

Preferred Qualifications

• Bachelor’s degree from an accredited institution

• Previous experience in dental insurance or working in a dental office setting

• Comprehensive understanding of American Dental Association (ADA) codes

• Demonstrated customer service experience, preferably in a healthcare or insurance environment