Claims Processor

NationsBenefits is recognized as one of the fastest-growing companies in America and a Healthcare Fintech provider of supplemental benefits, flex cards, and member engagement solutions. We partner with managed care organizations to provide innovative healthcare solutions that drive growth, improve outcomes, reduce costs, and bring value to their members.

Through our comprehensive suite of innovative supplemental benefits, fintech payment platforms, and member engagement solutions, we help health plans deliver high-quality benefits to their members that address the social determinants of health and improve member health outcomes and satisfaction.

Our compliance-focused infrastructure, proprietary technology systems, and premier service delivery model allow our health plan partners to deliver high-quality, value-based care to millions of members.

We offer a fulfilling work environment that attracts top talent and encourages all associates to contribute to delivering premier service to internal and external customers alike. Our goal is to transform the healthcare industry for the better! We provide career advancement opportunities from within the organization across multiple locations in the US, South America, and India.

Position Summary

The Claims Processor accurately adjudicates dental claims for approximately 400,000 members effective January 1, 2027. The role reviews, prices, and pays or denies claims in line with plan benefits, state regulations, and company policies, and routes claims needing clinical judgment to the clinical review process. Utilization review recommendations are provided by our partner, Fluent, whose clinical dental directors cover all fifty states.

Key Responsibilities

• Adjudicate dental claims (ADA/CDT coded) from work queues, applying member benefits, fee schedules, frequency and age limitations, waiting periods, deductibles, maximums, and coordination of benefits.
• Review pended claims, attachments, narratives and x-rays for completeness and identify claims requiring clinical review.
• Refer claims to the hygienist team or to Fluent for clinical recommendations, then apply the recommendation correctly and document the outcome.
• Process adjustments, reprocessing, refunds, overpayment recoveries, and corrected claims.
• Research and resolve claim inquiries from Customer Service, providers, and members; document actions clearly in the claim notes.
• Meet daily productivity, quality, and turnaround targets, including state prompt-pay timelines.
• Identify trends, system errors, and benefit configuration issues and escalate to leadership.
• Protect PHI and follow HIPAA, privacy, and compliance requirements at all times.
• Participate in training, quality audits, and user acceptance testing ahead of go-live.

Qualifications

• High school diploma or equivalent required; associate or bachelor degree preferred.
• 2+ years of dental or health insurance claims processing experience required.
• Working knowledge of CDT codes, dental terminology, EOBs, and coordination of benefits.
• Experience with a claims adjudication platform; strong data entry accuracy and typing skills.
• Strong attention to detail, time management, written communication, and customer service skills.
• Ability to meet productivity and accuracy standards (e.g., 98% financial and 95% procedural accuracy).
• Proficient in Microsoft Office; comfortable with multiple systems and imaging viewers.

Preferred

• Experience with Medicare Advantage, Medicaid, or commercial dental plans.
• Prior experience working alongside clinical review or utilization management partners.
• Bilingual (English/Spanish).

Performance Measures

• Claims processed per day (target to be set from final capacity model)
• Financial and procedural accuracy from audits
• Turnaround time and inventory aging within regulatory timelines
• Rework/adjustment rate
• Compliance and documentation quality

Working Conditions

Primarily sedentary computer-based work in a production environment. Standard hours with possible overtime during launch and peak periods.