Claims Examiner

Posted 2 Days Ago
Be an Early Applicant
Alpharetta, GA, USA
In-Office
37K-75K Annually
Mid level
Healthtech • Insurance
To improve health by providing access to quality care. #LifeatDDins #DeltaDentalCares
The Role
Administratively review, analyze, and adjudicate insurance claims for accuracy, eligibility, coverage, and benefit application. Validate documentation, identify discrepancies or potential fraud, coordinate with providers and internal teams, apply policy and regulatory rules, ensure compliant claim outcomes, and meet productivity and quality standards while supporting process improvements.
Summary Generated by Built In
The Claims Examiner is responsible for administratively reviewing, analyzing, and adjudicating claims of varying complexity. This role focuses on non clinical decision making and ensures processing integrity by validating accuracy, completeness, eligibility, coverage, and benefit application across all claims systems. The Claims Examiner reviews supporting documentation, identifies discrepancies or potential fraud, resolves issues through coordination with internal and external stakeholders, and ensures all claim outcomes align with policy, regulatory requirements, and established procedures. Responsibilities
  • Review and analyze claim submissions across all claims processing systems to ensure completeness, accuracy, eligibility, and appropriate documentation
  • Verify coverage, pricing, authorizations, coordination of benefits (COB), and member eligibility in alignment with policy and regulatory requirements
  • Apply policy provisions, benefit guidelines, and regulatory rules to accurately adjudicate all administrative claim types, including in and out of network claims.
  • Identify and address discrepancies such as incorrect billing, duplicate claims, or potential fraud indicators, escalating issues as appropriate
  • Determine and apply accurate benefit payments in accordance with organizational standards and required regulatory timeframe
  • Communicate with providers, enrollees, and internal teams to obtain missing or clarifying information and support timely claim resolution
  • Investigate complex or questionable claims to validate documentation and ensure claim integrity
  • Maintain accurate claim documentation and ensure compliance with HIPAA, privacy requirements, and all applicable regulations
  • Meet established productivity and quality standards while contributing to process improvements and staying current with policy updates and regulatory changes
  • Qualifications
    • 3+ years of experience w/High School
    • 2+ years’ experience in a similar role; Associate degree preferred. Required to successfully complete claim examiner training and examinations.
    • Proficient in basic computer operations and Microsoft Office Suite programs (Excel, Outlook, Word, etc)
    • Effective written, verbal, and interpersonal communication skills to document claim decisions and communicate with internal partners and external clients
    • Ability to review information, identify the appropriate resolution, and recommend actions that ensure accurate, consistent, and outcome aligned results
    • High attention to detail to identify errors, inconsistencies, or missing documentation in claims
    • Ability to adapt quickly in fast-paced or changing environment
    • Ability to work effectively both independently with minimal supervision and collaboratively as part of a team
    • Knowledge of Delta Dental systems/organization and knowledge of health care industry issues preferred.

    Base Pay Information
    The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental’s assessment of the candidate’s knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity. 
    Pay Grade 14. $36,900 - $74,600

    About UsBehind the smile! We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. Our life-changing rewards package includes:
    • Competitive base and incentive pay 
    • 401(k) with robust matching and non-matching contributions
    • Rich medical & pharmacy benefits
    • 100% employer-paid dental and vision benefits
    • Holistic wellbeing program with deep financial incentives
    • Generous paid time off plus 12 paid holidays and your birthday off
    • Culture of growth and learning: career development; tuition reimbursement; recognition program
    • Family support: adoption assistance, fertility treatment, child, elder & pet care assistance
    • Social responsibility and volunteer opportunities
    • Employee discount program
    Fair Chance Ordinances and Criminal Background Considerations 
    This position requires that the applicant undergo a background check. Qualified applicants with arrest or conviction records will be considered for employment in accordance with any applicable federal, state or local laws, including, but not limited to, the California Fair Chance Act, the Los Angeles County Fair Chance Ordinance, the City of Los Angeles Fair Chance Initiative for Hiring Ordinance, the San Francisco Fair Chance Ordinance, and/or New York Corrections Law Article 23-A.
     
    Important Work Authorization Information 
    Please note, Delta Dental will not sponsor applicants for work visas for this position.

    #LI-Hybrid
    About the Team
    At Delta Dental, we’re behind millions of smiles and counting. For over 68 years, we’ve served our communities by increasing access to affordable, quality care – but that commitment to care extends beyond the people we serve, to the dedicated employees who make those smiles genuine. We've come this far by building fair programs that offer opportunities for advancement, create meaningful connections and improve the lives of our employees and their families. Because we know that when we take exceptional care of each other, we can make a positive impact for all.

    We champion an inspirational workplace through our commitment to trust, service, excellence and innovation. Joining us means working for a company that offers stability and balance, opportunities for leadership at all levels, and a work environment focused on teamwork and camaraderie.

    Discover the smiling faces behind Delta Dental and experience our values and culture in action by connecting with us on social media. Follow Delta Dental Ins. on Facebook and Instagram, #LifeatDDins on Facebook and Instagram, Delta Dental Ins. on Twitter and Delta Dental Ins. on LinkedIn. If you've got an appetite for innovation and want to be a part of a team that’s transforming the future of health care, join us!

    Since 1955, we have offered comprehensive, high-quality oral health care benefits to millions of enrollees and built the strongest network of dental providers in the country. The Delta Dental of California network includes affiliates Delta Dental Insurance Company; Delta Dental of Pennsylvania; Delta Dental of New York, Inc.; Delta Dental of the District of Columbia; Delta Dental of Delaware, Inc.; and Delta Dental of West Virginia, providing dental benefits to more than 31 million people across 15 states, the District of Columbia, Puerto Rico and the Virgin Islands.

    The company and its affiliates are part of Delta Dental Plans Association (DDPA), a not-for-profit national association based in Oak Brook, Illinois. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories. We offer vision coverage through DeltaVision in 15 states and the District of Columbia. Collectively, we deliver benefits to more Americans than any other dental insurance company.

    Delta Dental Ins. is an equal opportunity employer and is committed to providing a professional work environment free from discrimination and harassment.  Individuals seeking employment at Delta Dental are considered without regard to race, ethnicity, color, age, sex, religion, national origin, ancestry, pregnancy, sexual orientation, gender identity, gender expression, genetic information, actual or perceived physical or mental disability, registered domestic partner status, caregiver status, marital status, veteran or military status, citizenship status, or any other legally protected category.  Delta Dental is committed to providing equal employment opportunities to all employees and applicants for employment. Accordingly, we have adopted and maintain an Equal Employment Opportunity Policy, Harassment-Free Work Environment Policy, and Respectful Workplace policies and will not tolerate violations of these policies.

    Unfortunately, our Delta Dental Enterprise is unable to hire individuals residing in Alaska, North Dakota, Nebraska, Hawaii, Oklahoma, Vermont, Maine, West Virginia, New Hampshire, Wyoming, Puerto Rico, District of Columbia (Washington D.C.) or other US Territories at this time.

    Proof of eligibility to work in the United States must be provided if selected for hire.

    *Delta Dental includes: Delta Dental of California, Delta Dental Insurance Company, Delta Dental of Pennsylvania, and Delta Dental of New York

    If You Are A Current Employee Click Here To Apply

    Skills Required

    • 3+ years of experience with High School education
    • 2+ years experience in a similar role
    • Successfully complete claim examiner training and examinations
    • Proficient in basic computer operations and Microsoft Office Suite (Excel, Outlook, Word)
    • Effective written, verbal, and interpersonal communication skills
    • Ability to review information, identify appropriate resolution, and recommend actions
    • High attention to detail to identify errors, inconsistencies, or missing documentation
    • Ability to adapt quickly in a fast-paced or changing environment
    • Ability to work independently with minimal supervision and collaboratively as part of a team
    • Associate degree
    • Knowledge of Delta Dental systems and healthcare industry issues

    Delta Dental Insurance Company Compensation & Benefits Highlights

    The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Delta Dental Insurance Company and has not been reviewed or approved by Delta Dental Insurance Company.

    • Retirement Support Retirement support is positioned as a standout element, including a sizable automatic 401(k) contribution plus additional matching. This boosts overall total-rewards value even when base pay is viewed as only mid-market in some areas.
    • Affordable Benefits Core coverage is framed as unusually low-cost to employees, including fully employer-paid dental and vision and low employee contribution medical options. This creates meaningful take-home value beyond cash compensation.
    • Leave & Time Off Breadth Time-off offerings are described as generous, including broad PTO/holidays and additional paid leave features such as parental leave. These policies increase perceived rewards and help balance workload demands.

    Delta Dental Insurance Company Insights

    Am I A Good Fit?
    beta
    Get Personalized Job Insights.
    Our AI-powered fit analysis compares your resume with a job listing so you know if your skills & experience align.

    The Company
    HQ: San Francisco, California
    5,975 Employees
    Year Founded: 1955

    What We Do

    At Delta Dental, we’re behind millions of smiles and counting. For over 68 years, we’ve served our communities by increasing access to affordable, quality care – but that commitment to care extends beyond the people we serve, to the dedicated employees who make those smiles genuine. We've come this far by building programs that offer opportunities for advancement, create meaningful connections, and improve the lives of our employees and their families. Because we know that when we take exceptional care of each other, we can make a positive impact for all. We champion an inspirational workplace through our commitment to trust, service, excellence and innovation. Joining us means working for a company that offers stability and balance, opportunities for leadership at all levels, and a work environment. Delta Dental of California, Delta Dental of New York, Inc., Delta Dental of Pennsylvania, and Delta Dental Insurance Company are members, or affiliates of members, of the Delta Dental Plans Association, a network of 39 Delta Dental companies throughout the country. Together with our affiliate companies, form one of the nation’s largest dental benefits delivery systems, covering over 31 million enrollees. Headquartered in San Francisco, we are members of the Delta Dental Plans Association, a network of companies that provides dental coverage to 80 million people. Delta Dental provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Delta Dental complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

    Similar Jobs

    In-Office
    2 Locations
    2600 Employees
    47K-70K Annually
    In-Office
    6 Locations
    3519 Employees
    98K-134K Annually
    In-Office
    8 Locations
    3519 Employees
    28-38 Hourly
    In-Office or Remote
    6 Locations
    2470 Employees
    80K-110K Annually

    Similar Companies Hiring

    Sailor Health Thumbnail
    Healthtech • Social Impact • Telehealth
    New York City, NY
    20 Employees
    Granted Thumbnail
    Mobile • Insurance • Healthtech • Financial Services • Artificial Intelligence
    New York, New York
    23 Employees
    OneImaging Thumbnail
    Healthtech
    Miami, FL
    62 Employees

    Sign up now Access later

    Create Free Account

    Please log in or sign up to report this job.

    Create Free Account