Claims Examiner
About Us
Delta Dental of New Jersey and Delta Dental of Connecticut are proud to be leaders in the dental insurance industry, offering a wide range of plans to meet the needs of individuals and employers alike. As New Jersey’s largest dental coverage provider, we are committed to delivering high-quality, cost-effective solutions designed to meet the diverse needs of our customers and our team is growing.
In Connecticut, Delta Dental of Connecticut, Inc. provides fully insured dental coverage, while Delta Dental of New Jersey administers self-funded dental benefit programs. We proudly serve over 1.7 million individuals through more than 1,800 groups, including commercial, school board, and government programs.
Since 1969, Delta Dental has been at the forefront of innovation, offering programs that control costs while ensuring the highest level of benefits.
As a member of the national Delta Dental Plans Association, we provide national dental coverage to over 75 million people across 139,000 groups. Our commitment to excellence is reflected in our prestigious Standard & Poor’s “A+” rating for financial strength. Join us and be a part of a trusted company with a rich history of delivering quality dental benefits to millions.
We value our associates and support everyone with learning and development, active wellness and diversity initiatives, and volunteer opportunities at causes that you care about.
About the Position
Our Claims Examiners are provided with established company guidelines and examine and adjudicate dental claims using these guidelines, with expected levels of quality and productivity.
The expected Start date for this position is April 20th, 2026.
Essential Functions & Responsibilities
- Accesses systems and keys claim data and other information and notations from work queues. Suspends, routes and adjudicates claims and performs research as required. Also, inputs fee filing data, as required
- Creates and processes claims for pre-treatment estimates with payments.
- Maintains and updates subscribers files with information obtained through inquiries and submitted claims and documents, i.e., family on hold codes applied or removed, student status deferred, addresses updated. Reports file discrepancies to management.
- Responsible for researching and retrieving all documentation and resolving all claims in question, including student documentation, provider research, some coordination of benefits, diagnostics materials, etc.
- Understands rejects and applies appropriate RFS codes as well as processing policies on applicable claims.
- Requests information from providers and subscribers through telephone contact or written correspondence.
- Resolves claims related system generated error and adjustment reports.
- Supports and participates in completing claims related projects.
- Acquire necessary skills through in-house training for Claim Examiner II position. Achieve Level II position within 36 months from start of Claims Examiner I.
- When necessary, refers inquiries to management, dental consultants or appropriate outside organizations.
- Provides management with required production figures as requested.
- Other duties as assigned
Essential Qualifications
Competencies
Adaptability-Flexibility | Communication Skills |
Computer Skills | Customer Focus |
Dependability | Job Knowledge |
Productivity | Quality |
Teamwork |
|
Technical and Functional
- Personal computer skills with the ability to type 25 words per minute
- Possess the ability to use Microsoft Word and Excel
- Excellent written and oral communication skills
- Ability to research and troubleshoot problems
- Demonstrate good analytical and proofreading skills
- Attention to detail
- Good organizational skills
Key Performance Indicators
- Meet-exceed CPH of 30 or above
- Maintain TQM of 99% or higher
Required Physical Abilities
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Ability to sit and perform extensive close keyboard and PC work
- Ability to walk, talk or hear
- Occasionally required to stand and reach with hands and arms
Working Environment
- Ability to meet deadlines and attendance standards.
- The noise level in the work environment is usually moderate.
- This classification will be required to sign a confidentiality agreement.
Experience, Education and Certifications Required
Experience Required
- 1-3 years claims processing or related service experience
- Dental Assistant education/experience preferred
Required Educational Level
- Requires high school diploma or equivalent.
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