Insurance Operations Manager, CarePlus Dental Plans (Hybrid)

About the position We are seeking an experienced benefits manager to oversee benefits administration, data analytics, and the insurance technology platform for CarePlus Dental Plans, the vertically integrated dental insurance arm of Dental Associates. The ideal candidate will be an analytical self-starter who excels at problem solving and attention to detail. The CarePlus Insurance Operations Manager will act as a liaison between our service, technical, and operations staff, with a core focus on providing excellent administrative support to our clients and provider partner, Dental Associates.

• Responsibilities
• Build strong relationships within the business units and support functions to better serve our members.
• Create, transmit, import, adjudicate and pay claims for timely processing
• Process claims specific to the agreed upon benefits and fee schedules by plan, reviewing clinical documentation as needed.
• As appropriate, determine alternate benefits for services that do not meet processing guidelines.
• Ensure the accuracy of claim payment for all claims processed through the extended provider network.
• Submit out of network claim payment approvals, including supporting documentation within protocol.
• Communicate denial reasons with providers and patients per policy guidelines.
• Collaborate with leadership to establish work standards and objectives with Major Work Coordinators.
• Identify and report potential fraud and abuse cases.
• Identify and translate business needs into clearly defined requirements for insurance policy administration projects.
• Manage client relationships including but not limited to initial set up, ongoing processing and troubleshooting of HIPAA 834 electronic enrollments and ACH transfers.
• Create and maintain documentation, including HIPAA 834 Companion Guides.
• Handle analysis, audits and supervisor support for Dental Associates’ Billing Department upon request.
• Configure benefits within the Skygen Insurance and Denticon Practice Management systems, including plan structure and fee schedules.
• Lead software testing, documentation and validation periodically, in preparation for software upgrades.
• Collaborate with team members on system enhancements, ensuring that proposed solutions improve efficiency and the effectiveness of business processes.
• Identify software performance issues, obtaining resolution through working with vendors.
• Evaluate reporting for accuracy, resolving inaccuracies with IT and third-party administrators.
• Other duties as assigned.
• Requirements
• Ability to work collaboratively with key internal and external leaders, partners, payers, and customers in a fast-paced environment.
• Excellent interpersonal, communication, and organizational skills. Demonstrate professional and ethical standards to gain and maintain credibility.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit the targeted audience, presentation, and communication skills.
• Must be knowledgeable about dental insurance programs & plan offerings.
• Ability to investigate technical issues and work both independently and within a team.
• Conceptual thinking ability to define problems, collect data, establish facts, and draw valid conclusions.
• Bachelor’s degree in business, healthcare management or equivalent combination of education, training, and experience.
• Wisconsin Insurance License within 90 days of hire
• Minimum of five years’ experience in a benefit specialist, analyst or management type role.
• Prior experience with PHI and HIPAA Compliance.
• Experience in account receivables preferred.
• Working knowledge of insurance related financial terminology.
• Nice-to-haves
• Experience in account receivables preferred.
• Benefits
• Flexible PTO
• Medical Insurance with optional Health Savings Account through Associated Bank
• Dental: Diagnostic and Preventive covered at 100%, Basic and Restorative (immediate family)
• Vision Insurance
• Life Insurance
• 401k
• Company paid short term disability
• Paid Holidays
• FSA
• Critical Illness
• Hospital Indemnity
• Pet Insurance

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