Medical Claim Submission Specialist

Position Purpose

The position will be responsible for medical claims submission with regards to recommended dental treatment that meets medical necessity. The position will cross code dental and medical for claims submission. Communication with dental providers and medical plan providers will be needed to interpret data and request documentation from dental providers when necessary. The position will also be responsible for claim follow through, pending claims, denials, and appeals adjudication.

Objective / Detailed Responsibilities

The objective is to enable our CareRevenue clients to utilize medical benefits in the practice. These responsibilities include, but are not limited to:

If Prior Authorization was not needed, begin the documentation process for claim.

If Prior Authorization is needed, will submit appropriate medical CPT codes Valer.

Review data from dental providers to align with medical necessity outlined by policy criteria and limitations. Ensuring the supporting documentation has been provided.


Request additional information from the provider if the claim does not meet the requirement prior to submission.

Once pre-determination has been received communication with the provider regarding status.

Once treatment has been approved and rendered, begin the initial claim process for submission.

Ensure the supplemental information meets the criteria added to the claim prior to submission.

Correlation of CDT codes to associated CPT codes for claim form CMS 1500

Review finale claims ensuring accuracy and completeness.

Monitor claims through the cycle. Communication with the health plan during the process to ensure claims are moving.

Liaison between Dental Provider and Health Plan to provide additional documentation when requested.

Claim status favorable documentation and close.

When necessary, the Appeal process initiated with additional documentation collected from the provider.

Communication with the Dental Provider on the final determination of the Appeal Process.

Update claim status. If eligible for dental reimbursement, hand off to dental.

Qualifications and Experience

The ideal candidate will have a Medical background and ability to interpret clinical documentation and the concept of medical necessity. The candidate should have a knowledge of workflow with claims submission process, including interaction with dental / health plans. This substantial work experience will allow the candidate to understand the dynamics and challenges faced by dental and health providers as well as the solutions and business processes that CareRevenue provides.

The ideal candidate will also demonstrate superior communication skills as well as the ability to interact effectively across a multi-disciplinary work group, maintaining composure, confidence and professionalism in all interactions.