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Operations Analyst

Operations Analyst

Delta Dental of Rhode IslandProvidence, RI, US
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Job Description

Job Description

POSITION SUMMARY : This position is an integral part of the Operational team. In this role, the analyst will assist in various Operational processes including; new client setup, management of client, system configuration, claims resolution, and quality control of client related transactions. This individual will be a key resource to answer inquiries from other areas throughout the company.

Essential Functions :

Client Setup

  • Record system transactions to account for any changes in a client’s general and / or benefit information.
  • Quality control checks of all system transactions.
  • Serves as a resource to the organization regarding processing of client related information and transactions.
  • Maintain and process client renewal transactions.

System Configuration

  • Research and configure system rules based off client benefit modifications, CDT updates and companywide policy changes.
  • Propose new innovative rules to Management that enhance the claim processing system that will help build efficiencies and increase accuracy.

    • Claims Resolution

  • Plans, allocates, and monitors workflow to assure the accurate and timely completion of assignments within established production and inventory standards.
  • Assists in the oversight of the processing and adjudication of claims by guiding the activities of the claims analysts; monitors and communicates corporate policies and procedures to assure a high level of accuracy and completeness within established production and inventory standards.
  • Researches any unusual payments and refunds; processes the most complex type of claims which involve judgment and interpretation based on precedent, knowledge of the dental terminology, and a thorough understanding of the Corporation’s claims processing policies and procedures.
  • Research and resolve potential client overpayments and underpayments.
  • Performs the overpayment recovery process to recoup overpayments made to the dentists.
  • Interact regularly with Customer Service to answer claim-related questions.

    • Data Analysis and Reporting

  • Becomes knowledgeable with analytical tools and collaborates / recommends new operational reports to Data Analytics team.

    • Quality Control

  • Responsible for the quality of various operations department tasks including rule updates, coordination of benefit processing, ortho claims, internally entered claims pretreatments and client data management.

    • Testing

  • Assists in the evaluation of all system releases to ensure accuracy and completion.
  • Participates in pre-release testing with Project Management

    • Other Duties

  • Participates in special projects as required by management.
  • Performs other duties as assigned.

    • Requirements :

  • High School Diploma or equivalent; Associates or Bachelor’s degree preferred.
  • Excellent communication and organizational skills.
  • Attention to detail and accuracy.
  • Prior knowledge of database programs preferred.

    • Entry Level Training Received (If any)

  • Extensive training in claim, eligibility, and provider functions as well as workstation training.

    • Work Environment / Physical Demands :

  • Typical office environment

    • Attendance Requirements :

  • 40-hour workweek (M-F) as assigned and additional hours as required
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    Analyst • Providence, RI, US