Dental Eligibility Specialist

ESSENTIAL DUTIES / RESPONSIBILITIES

Verify patient dental insurance eligibility and obtain comprehensive breakdowns of benefits prior to scheduled appointments and treatment.
Use payer portals, electronic eligibility tools, and direct telephone contact with insurance carriers to obtain, clarify, and validate benefit information.
Contact insurance payers by telephone when information is unavailable, incomplete, unclear, or conflicting. Telephone verification is a required function of this job.
Accurately enter and maintain eligibility and detailed benefit information in Epic according to established workflows and documentation standards.
Obtain, interpret, and document dental benefit information, including, but not limited to, annual maximums, deductibles, coverage percentages, frequencies, limitations, exclusions, orthodontic benefits, coordination of benefits, and applicable treatment history.
Use knowledge of dental terminology and CDT procedure codes to research procedure-specific benefits and identify information that may affect treatment planning, patient financial estimates, billing, or claims processing.
Identify discrepancies or missing information, perform additional research as needed, and escalate unresolved issues to appropriate teams.
Maintain established productivity, accuracy, quality, turnaround, documentation, privacy, and HIPAA standards.
 

QUALIFICATIONS

Minimum Education and Experience

This section is assigned automatically in JDXpert based on the approved career stream and job level and should not be edited. Confirm the applicable standard with Organizational Effectiveness and Compensation.
 

Additional Experience and Education

Three or more years of dental insurance eligibility, dental benefits verification, dental billing, dental revenue cycle, or dental practice experience required.
Experience working with dental insurance plans, payer portals, and benefit verification processes required.
Experience contacting dental insurance carriers by telephone and working directly with payer representatives to obtain detailed eligibility and benefit information required.
Experience interpreting dental insurance benefits, frequencies, limitations, exclusions, deductibles, maximums, coverage percentages, and treatment history required.
Experience working with CDT procedure codes and dental terminology required.
Experience entering detailed insurance benefit information into a dental practice management system or electronic health record required.
Experience with Epic dental eligibility, coverage, or benefit workflows preferred.
Experience supporting multiple dental practices or locations preferred.
 

Knowledge, Skills, and Abilities

Required: Advanced knowledge of dental insurance eligibility, benefit verification processes, dental terminology, and common CDT procedure codes.
Required: Knowledge of dental benefit structures, including annual maximums, deductibles, coverage percentages, frequencies, age limitations, waiting periods, replacement provisions, exclusions, orthodontic benefits, and coordination of benefits.
Required: Skill in navigating multiple payer portals, electronic eligibility systems, and other insurance resources efficiently and accurately.
Required: Skill and confidence in contacting insurance carriers by telephone and communicating directly with payer representatives to obtain, clarify, and validate detailed benefit information.
Required: Ability to recognize incomplete, conflicting, or unclear benefit information and determine when additional research or direct payer contact is required.
Required: Ability to interpret payer responses and accurately translate complex dental benefit information into standardized documentation within Epic.
Required: Strong attention to detail, data accuracy, and ability to identify discrepancies or missing information that could affect treatment planning, billing, claims processing, or patient financial estimates.
Required: Strong verbal, written, and professional telephone communication skills.
Required: Ability to work efficiently across multiple systems and applications while managing a high-volume workload and meeting established productivity, quality, and turnaround expectations.
Required: Ability to work independently, prioritize effectively, exercise sound judgment, follow established workflows, and demonstrate ownership and accountability.
Preferred: Working knowledge of Epic dental insurance coverage, eligibility, and benefit documentation workflows.
Preferred: Experience with dental practice management systems such as Dentrix, Denticon, Eaglesoft, Open Dental, Dentrix Ascend, or similar systems.
Preferred: Knowledge of PPO, Medicaid, DHMO, and other dental plan structures.
 

Licenses and Certifications

Epic training or certification will be required within the timeframe established by the business after hire.
 

Professional Competencies

Professional competencies will auto-populate in JDXpert based on the approved Individual Contributor designation and cannot be modified in the job description workflow.
 

PHYSICAL, MENTAL, AND ENVIRONMENTAL REQUIREMENTS

The People Team will determine and auto-populate the applicable requirements in JDXpert after the job description is submitted and reviewed. The role includes computer-based work, regular telephone communication with insurance carriers.