Senior Dental Benefits Specialist

🔥 12 hours ago

🌪️ Kansas – Remote

🌪️ Kansas – Remote

💵 $63.3k - $80.1k / year

⏰ Full Time

🟠 Senior

👩‍👩‍👧‍👦 Human Resources (HR)

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GEHA Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1937

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

GEHA Health is a large benefits association dedicated to serving federal employees, retirees, and their families. Founded by postal workers in 1937, GEHA offers a comprehensive range of health and dental plans, including FEHB and PSHB options, as well as additional benefits such as gym memberships, vision benefits, and wellness rewards. With a network of 1. 7 million providers nationwide and extensive prescription drug coverage, GEHA prioritizes reinvesting profits to enhance member experiences and support federal workforce health. Their plans include Medicare Advantage options and a robust telehealth offering, ensuring their members receive the best possible care and coverage.

📋 Description

• Ensure second-level appeal documentation is accurate, complete, defensible, and consistent with plan provisions, benefit policies, and clinical appropriateness criteria • Independently determine documentation sufficiency, need for additional clinical review, and whether case records support final determinations • Own the end-to-end clinical review pathway between G.E.H.A.'s TPA and clinical review vendor • Prepare organized case summaries and supporting documentation for timely determinations • Track appeal status, review rationale, and outcomes within established turnaround standards • Review determination letters and correspondence for accuracy and completeness • Maintain organized, audit-ready appeal case files • Identify appeal volume, denial reason, and determination outcome trends for the Manager, Dental Product • Serve as escalation point for complex or contested appeal documentation questions • Conduct random and directed post-payment claims audits • Review paid dental claims against plan provisions, CDT coding standards, and benefit limitations • Identify overpayments, billing errors, coding irregularities, and potentially improper payments • Prepare clear audit findings reports with irregularity details, dollar amounts, and supporting rationale • Maintain audit records and tracking logs • Identify systemic billing patterns and recurring coding issues • Determine audit scope and sampling approach for directed reviews • Serve as G.E.H.A.'s internal dental subject matter expert on benefit interpretation, CDT coding, claim adjudication logic, and plan provisions • Support benefit policy interpretation, OPM filings, benefit design reviews, member escalations, and dental-specific reviews • Provide guidance to internal partners and TPA staff on dental benefit provisions and CDT coding standards • Review member-facing dental education content for clinical and benefit accuracy • Assist with updating educational materials in line 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 preferred • Additional years of qualifying relevant work experience may be considered in lieu of formal education • Dental clinical training, certification, or licensure (RDH or equivalent) strongly preferred; equivalent applied dental clinical knowledge gained through sustained dental claims, appeals, or utilization review practice will be considered • Minimum of 5 years of experience in dental claims review, dental benefits administration, or dental appeals processing in a health plan or managed care environment • Demonstrated independent ownership of appeal documentation, clinical review coordination, or claims audit work • Advanced working expertise in dental benefit administration, CDT coding, dental claims adjudication, coordination of benefits, dental benefit structures, and common billing practices • Direct experience supporting appeal documentation, coordinating clinical reviews, or conducting claim audits in a dental insurance or managed dental care setting required • Ability to independently evaluate coding accuracy, benefit application, claim adjudication logic, and payment appropriateness in complex dental claims and appeal scenarios • Ability to exercise independent judgment and work without routine supervision • Ability to explain benefit, coding, and adjudication reasoning clearly to non-dental colleagues and external partners • Sound analytical and clinical reasoning skills • Excellent written communication skills • Meticulous attention to detail and a quality-first approach • Organized and deadline-driven; able to manage concurrent appeals and audit assignments • Ability to work 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 a plus • Experience applying clinical appropriateness criteria or benefit plan provisions preferred • Experience reviewing written determination letters or preparing audit findings reports preferred • Experience serving as a dental subject matter resource or working directly with a TPA or clinical review vendor strongly preferred • Ability to 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 • Latency response time lower than 80 ms • Hotspots, satellite, and wireless internet service are not allowed • Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Competitive pay/salary ranges • Incentive plan • Health/Vision/Dental benefits effective day one • 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution • Robust employee well-being program • Paid Time Off • Personal Community Enrichment Time • Company-provided Basic Life and AD&D • Company-provided Short-Term & Long-Term Disability • Tuition Assistance Program • Remote work opportunity • Hybrid and work-from-home options for many roles