Job details

Dental Claims Specialist IV

As a Dental Claims Specialist IV, you are responsible for maintaining a regular clinical review schedule of a minimum of 32 hours per week (required regular schedule of 4 x 8-hour days with hours between 6am-7pm PST Monday-Friday) or a minimum of 24 hour per week (required regular schedule of 3x 8-hour days with hours between 6am-7pm PST Monday-Friday) , with expected 24-48-hour turnaround time for items available for clinical review and peer to peer phone calls.

This position reports to the Assistant Dental Director

You Will:

Provide clinical review of predeterminations, claims, and/or appeals by accurately reviewing radiographs and/or other diagnostic information to determine claim decision in accordance with Guardian clinical guidelines. May also include other responsibilities, such as completion of assigned Peer to Peer calls, participation in panel review of clinical determinations, completion of Clinical Grievance reviews, and participation in credentialing meetings
Be responsible for maintaining quality work ensuring that review determinations are sound and supported by the diagnostic materials submitted and in accordance with Guardian Clinical Policies. Success in this role will be measured based on a combination of production and quality metrics
Support implementation of any new clinical review policy/criteria recommended by Dental Officer, Dental Standards & Quality Management and maintain awareness of continuous updates as pertaining to clinical review

Functional Skills

In-depth knowledge of CDT codes, procedures, and dental insurance concepts
Strong knowledge of Guardian dental clinical policies and guidelines
Ability to manage multiple workloads with multiple deliverables
Adapts to changing business priorities and environments

Leadership Behaviors:

Demonstrates the courage to make difficult decisions and have candid conversations
Sets and achieves high performance standards
Continuously strives to provide superior/professional customer service
Expresses oneself in an open and honest manner
Demonstrates self-awareness and embraces feedback

You Have:

Degree from ADA approved dental school
Minimum 10 years clinical practice
Dental License in a minimum of one state (Licensure in multiple states, especially NJ, TX, CA, preferred), Periodontist preferred
Strong communication skills
Strong computer skills with proficiency in Windows-based programs; including, but not limited to Outlook, Teams, Internet Explorer, and Chrome

Our Promise

At Guardian, you’ll have the support and flexibility to achieve your professional and personal goals. Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.

Salary Range

$68,890.00 - $127,930.00

The salary range reflected above is a good faith estimate of base pay for the primary location of the position. The salary for this position ultimately will be determined based on the education, experience, knowledge, and abilities of the successful candidate. In addition to salary, this role may also be eligible for annual, sales, or other incentive compensation.

Inspire Well-Being

As part of Guardian’s Purpose – to inspire well-being – we are committed to offering contemporary, supportive, flexible, and inclusive benefits and resources to our colleagues.

Health Care

Choice of [high deductible/copay] medical plans* with prescription drugs, including coverage for fertility and transgender inclusive benefits
Dental plan
Vision plan
Health care accounts – flexible spending, health reimbursement, and health savings accounts
Critical illness insurance

Life and Disability Insurance

Company-paid Life and Disability insurance plus voluntary supplemental coverage
Accident insurance

Retirement and Financial

401(k) retirement plan with a company match, plus an annual age/service-based Company contribution and an annual profit-sharing contribution, if applicable
Complimentary 1:1 financial guidance with a licensed Fidelity representative

Time Off and Remote Work

Flexible work arrangements (part in-person/part remote)
Unlimited paid time off for most roles plus time off for volunteering, jury duty, voting, and bereavement
Personal holidays for colleagues to use in recognition of religious, cultural, or civic days
Paid parental leave and paid family and medical leave policies

Emotional Well-being and Work-Life

Emotional well-being, mental health, and work/life resources powered by Spring Health
Wellness programs, including fitness program and equipment reimbursement
Child, adult, and elder back-up care support through Bright Horizons
Adoption assistance
College planning
Tuition reimbursement
Student loan assistance
Commuter benefits in select metropolitan areas

Justice, Equity, Diversity & Inclusion (J.E.D.I.)

Employee Resource Groups that advocate for inclusion and diversity
J.E.D.I. certification and training programs
Matching gifts/volunteering

Benefits apply to full-time eligible employees. Interns are not eligible for most Company benefits.

Equal Employment Opportunity

Guardian is an equal opportunity employer. All qualified applicants will be considered for employment without regard to age, race, color, creed, religion, sex, affectional or sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law.

Guardian is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact

applicant_accommodation@glic.com

By Guardian Life

In 2021, we expanded our purpose as an organization to inspire well-being™. We established Guardian’s North Star going forward and began a three- to five-year process of transformation and progress. The effort gained momentum last year across our ...

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FUNDING

Private

INDUSTRY

Insurance Carriers

TEAM SIZE

5001-10000

LOCATION

Hybrid, based in New York, NY

DATE POSTED