Position Title:

Claims Representative

Reports To:

Claims Manager

FLSA Status:

Full Time

Summary:

A dental Claims Representative adjudicates dental claims based on summary plan descriptions.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Sort daily mail into groups and separate claims that need to be reviewed by dental consultant (x-rays)

Adjudicate claims according to group guidelines. Review member history, eligibility, student status, coordination of benefits, member address, doctor address and other information to verify correctness.

Maintain departmental productivity and accuracy requirements.

Confer with Team Leads if treatment plan is not clear.

Review electronic claims.

Handle claim adjustments taken by customer service and distributed by Auditors.

Research to find correct address when EOB's and checks are returned. When applicable, make corrections and resend.

Return claims to provider/member when information has been omitted from the claim form.

Make sure claim numbers are written on all attachments to claim and given to the imaging department on a daily basis.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

One year certificate from college or technical school; or three to six months related dental assisting and/or insurance billing experience and/or training; or equivalent combination of education and experience.

Computer Skills:

Knowledge of Database software, strong alpha-numeric data entry skills.

Other Skills:

Knowledge of ADA codes, dental procedures and terminology.

Apply Now

Position Title:

Clinical Reviewer (Licensed Dentist)

Reports To:

Director of Utilization Management

FLSA Status:

Non-Exempt, Part-Time

Summary:

The primary function of the Clinical Reviewer is to review dental claim forms, treatment plans and other documents relating to the provision of dental services and impose, wherever applicable, the exclusions and limitations of the Companys dental benefit plans.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Review documents submitted by managed care and fee-for-service dentists in the manner set forth in the Companys policies.

Respond on a timely basis to inquiries from staff members regarding the provision of services to enrollees.

If requested, to participate as a member of the Quality Improvement Committee.

If requested, to participate as a member of the Utilization Review Committee.

If requested, to participate as a member of the Complaint and Appeals Review Committee.

Qualifications:

Licensed as a dentist under the laws of the State of New York, authorized to practice dentistry and currently approved by the Department of Education of the State of New York

or;

Licensed as a dentist under the laws of the State of New Jersey, authorized to practice dentistry and currently approved by the Department of Law & Public Safety, Division of Consumer Affairs of the State of New Jersey.

Have no history of any Medicaid/Medicare and/or other governmental regulatory sanctions.

Be properly credentialed by a Credentials Verification Organization.

Maintain a knowledge of current dental procedures, terminology and treatment codes.

Education And/Or Experience:

Be a graduate of an accredited dental school.

Have a minimum of ten (10) years experience in the dental field.

Computer Skills:

Other Skills:

Apply Now

Position Title:

Customer Service Representative

Reports To:

Director of Customer Service

FLSA Status:

Full Time

Summary:

A dental Customer Service Representative receives, investigates and responds to all customer inquiries regarding dental plan coverage, status of claims and provider information.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Talk with customers by phone concerning dental plan coverage issues.

Input comments regarding customer issue and relative data into the database.

Call customers when necessary to advise on next steps and/or inform of resolution.

Handle irate customers in a professional manner.

Obtain customer feedback information.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

High school diploma or GED.

Computer Skills:

Basic computer and keyboarding skills.

Other Skills:

Knowledge of dental procedures and terminology. Excellent communication skills. Good grammar, voice and diction. Bi-lingual English/Spanish/Russian helpful. Excellent customer service skills (friendly, courteous and helpful).

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Position Title:

Customer Service Representative Bi-lingual English/Spanish/Russian/Cantonese/Korean

Reports To:

Director of Customer Service

FLSA Status:

Full Time

Summary:

A dental Customer Service Representative receives, investigates and responds to all customer inquiries regarding dental plan coverage, status of claims and provider information.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Talk with customers by phone concerning dental plan coverage issues.

Input comments regarding customer issue and relative data into the database.

Call customers when necessary to advise on next steps and/or inform of resolution.

Handle irate customers in a professional manner.

Obtain customer feedback information.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

High school diploma or GED.

Computer Skills:

Basic computer and keyboarding skills.

Other Skills:

Knowledge of dental procedures and terminology a strong plus. Excellent communication skills. Good grammar, voice and diction. Bi-lingual English/Spanish/Russian/Cantonese/Korean. Excellent customer service skills (friendly, courteous and helpful).

Apply Now

Position Title:

Customer Service Representative- Web Support

Reports To:

Customer Service Director

FLSA Status:

Non-Exempt

Summary:

A Customer Service Representative in the Web Support division assists members and provider offices with website issues.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Answer high volume of inbound calls. Resolve member and provider issues concerning navigating the corporate website.

Reset password and help users register for online access.

Provide callers with assistance in navigating the website to access the information they require.

Educate callers on additional website features to help minimize use of a live Customer Service Representative.

Properly document calls according to the department standards.

Determine the proper area of Customer Service to transfer the call when the website feature cannot accommodate the caller. Follow appropriate avenues of protocol to elevate issues.

Meet or exceed standards of quality and professionalism as set by both Healthplex and the NCQA.

Adhere to all attendance/punctuality policies and procedures.

Ensure consistency and adherence to departmental workflows, policy and procedures.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

High school diploma or GED with (1-2) years of Customer Service Call Center experience preferred. Bilingual capabilities preferred but not required unless specificed.

Computer Skills:

Basic computer and keyboarding skills. Interney savvy. Familiarity with website terminology.

Other Skills:

Excellent verbal and written communication skills. Good grammar, voice, and diction. Excellent customer service skills (friendly, courteus and helpful).

Apply Now

Position Title:

Data Entry Technician

Reports To:

Claims Manager

FLSA Status:

Union; Non-Exempt; Full-Time

Summary:

A Data Entry Technician in the Claims Department is responsible for accurately entering data from claim forms.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Accurately enter high volume of dental claims data into company database.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

High school diploma or GED

Computer Skills:

Strong Data Entry Skills. Minimum data entry speed of 10,000 + keystrokes per hour required.

Other Skills:

Punctual, reliable, strong attention to detail skills required.

Apply Now

Position Title:

Emergency Referrals Representative

Reports To:

Utilization Manager

FLSA Status:

Non-Exempt

Summary:

An Emergency Referrals Representative receives inbound calls from Dental Provider Offices and provides emergency referrals within dental plan guidelines.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Provide emergency referrals to Dental Provider Offices

Provide professional and courteous service

Meet or Exceed standards of quality and professionalism as set by both Healthplex and the NCQA

Adhere to all attendance/punctuality policies and procedures

Ensure consistency and adherence to departmental workflows, policy and procedures

Follow appropriate avenues of protocol to elevate issues, if necessary

Accurately input comments to summarize the call into the database

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

High school diploma or GED. 1-2 years related experience preferred.

Computer Skills:

Basic computer and keyboarding skills.

Other Skills:

Excellent communication skills. Good grammar, voice and diction. Excellent customer service skills (friendly, courteous and helpful)

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Position Title:

Group Project Coordinator

Reports To:

Chief Financial Officer, Healthplex, Inc.

FLSA Status:

Exempt

Summary:

A Group Implementation Specialist provides administrative support as directed in all aspects of the group implementation and enrollment process.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Assist with the creation and distribution of new group and/or plan revision implementation spreadsheets.

Assist with monitoring the progress of new group implementation and/or revisions to existing groups.

Liaison and follow up with other departments to ensure tasks relating to group implementation and enrollment are completed

Assist with creating and documenting Enrollment department policies and procedures and periodically review for accuracy

Perform all aspects of Oracle database administration concerning small group set up, maintenance of provider data, group notes and other functions as directed

Ensure integrity of documents for Commercial business (ie: proof brochures, letters, fee schedules)

Assist with monthly Enrollment department audits

Assist with group inquiries

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

4-year degree or two + years’ related experience and/or training or equivalent combination of education and experience.

Computer Skills:

Microsoft Outlook, Excel, Word and Publisher, ability to type at least 55 wpm. Familiar with Oracle database systems a plus.

Other Skills:

Apply Now

Position Title:

Office Assistant Level 1

Reports To:

General Administration Support Supervisor

FLSA Status:

Non-Exempt; Full-Time

Summary:

Staff member in this position is responsible to accurately perform all essential duties.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Opening and Labeling Mail

Bar Coding Claims

Stamping EOBs

Pre-Sorting Claims into straight claims

Recording priority mail and bar code numbers

Return claims sent to Healthplex in error

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

High school diploma or GED

Computer Skills:

Basic computer skills a plus but not required.

Other Skills:

Apply Now

Position Title:

Outreach Representative

Reports To:

Director of Outreach

FLSA Status:

Non-Exempt, Part-Time, Temporary

Summary:

An Outreach Representative in the Government Services department works directly with members and provider offices to increase utilization and access / availability of services to members.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Reach out to members by phone and encourage them to utilize their coverage

Educate members on their dental benefits and provide members with assistance scheduling an appointment with a Healthplex dental office

Track and document member calls

Reach out to provider offices to provide education on increasing office visits of Healthplex members

Track and document provider calls

Work with provider offices and members in need of dental appointments to get appointments scheduled.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

High school diploma or GED with (1-2) years of Customer Service Call Center experience preferred. Excellent verbal and written communication skills. Bilingual Spanish and Cantonese a plus.

Computer Skills:

Basic computer and keyboarding skills.

Other Skills:

Apply Now

Position Title:

Provider Relations Assistant

Reports To:

Director, Provider Relations, Healthplex, Inc.

FLSA Status:

Non-Exempt

Summary:

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Research provider information for Oracle database updates

Track submitted provider updates in Oracle database

Compile and maintain current managed care provider panel mapping

Collect and distribute weekly managed care provider panel updates to department members

Perform research and information updates for monthly site visit issues

Perform research and information updates for monthly Cactus reports

Perform Access cleanup

Aid in list generation for provider panel recruitment

Handle provider calls for recruitment, information changes, website questions, etc.

Perform data entry as needed.

Manage and prepare materials for department daily needs and events, e.g., fee schedules, Provider Manual, etc.

Other duties as assigned

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

Bachelor's degree from four-year college or university; and three to four years related experience and/or training; or equivalent combination of education and experience.

Computer Skills:

Microsoft Outlook, Excel, Word and Access, Oracle, ability to type at least 55 wpm

Other Skills:

Strong communication skills, including writing and grammar. Background in Healthcare helpful

Apply Now

Position Title:

Provider Relations Representative

Reports To:

Provider Relations Manager

FLSA Status:

Non-Exempt

Summary:

A Provider Relations Representative performs all responsibilities relating to provider issues as outlined below.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Build and maintain dental provider panels by initiating and maintaining effective channels of communication with participating and prospective providers

Recruit providers as needed

Handle provider contracting and assist in negotiating fees

Communicate with panel doctors regarding plan changes and other issues

Validate and authorize all changes to the Oracle Provider Database by accurately completing top sheets

Respond to provider questions regarding participation, plans, fees and special requests

Interface with multiple departments (e.g. Claims, Customer Service, Credentialing Marketing) to research and resolve provider issues or to assist with special projects such as recruitment to support member growth

Reduce risk through quality assurance program

Develop and maintain directory data for all Locals and PPO groups

Periodically visit provider offices to orient office staff in policies, fee schedules and claims processing

Work as part of the Provider Relations Team in producing accurate Provider Directories, updating internal documents, reviewing mailing lists for accuracy, coordinating and attending sanctioned events, and promoting corporate and departmental initiatives

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

Bachelor of Science Degree (B.S.) plus 2-4 years experience or equivalent combination of education and experience in the dental healthcare industry.

Computer Skills:

Knowledge of Outlook Contact Management systems. Proficiency in Microsoft Software programs – Word, Excel, Access, Outlook. Ability to learn and successfully navigate proprietary programs.

Other Skills:

Ability to work as part of a team, communicate effectively with a variety of audiences, support a vision and direction, and to work independently within deadlines. Knowledge of dental procedures and terminology. Maintain a high level of professionalism and demonstrate sound judgment. Demonstrate the ability to successfully juggle a heavy and varied workload.

Apply Now

Position Title:

Quality Auditor - General

Reports To:

Internal Auditing Systems Specialist

FLSA Status:

Exempt

Summary:

A Quality Auditor audits and oversees in-house quality improvement initiatives as well as fulfills group audit responsibilities across any and all departments at Healthplex, Inc.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Directly assists Internal Auditing Department Management

Participates in collection and analysis of external audit files

Assists in report writing and data analysis activities

Assists in departmental policy and procedure development

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

Bachelors Degree with a concentration in Business Management, Mathematics, or a similar field, or relevant experience preferred. Familiarity with all plan structures and guidelines is necessary.

Computer Skills:

A strong command of Microsoft Office Software is required, specifically with Excel.

Other Skills:

Apply Now

Position Title:

Quality Management Associate

Reports To:

Director of Quality Management

FLSA Status:

Non-Exempt

Summary:

Investigates and resolves member complaints, appeals, grievances and fair hearings for Healthplex and client groups. Provide administrative support to Director of Quality Management and Vice President.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Provide written acknowledgment of all member and provider correspondence as it relates to member complaints, appeals and fair hearings.

Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.

Interface with Healthplexs internal departments, clients, and network providers to ensure resolution of case issues in a timely manner.

Compose correspondence related to processing of complaint, appeal and fair hearing cases including preparing correspondence to members, providers and clients, faxing and mailing correspondence, copying correspondence and supporting documents and creating a case file.

Enter notes in Oracle and MS Access as they relate to the initial investigation and resolution of the case.

Monitor pending case files and make necessary follow-up calls to internal and exernal entities to ensure that cases are completed on or before the applicable timeframe.

Document all actions taken in investigation for auditing and reporting purposes.

Prepare cases for review ensuring that all pertinent information (i.e. correspondence, internal and external responses, diagnosis, radiographs, dental chart) have been obtained during investigation and is presented as part of the case.

Open and distribute incoming mail daily.

Maintain files, scan and file cases on a weekly basis by client.

Answer incoming calls and assist caller when applicable.

Contact members and clients by telephone in order to investigate and resolve issues.

Other functions and projects may be assigned as business conditions change.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

Bachelor's degree from four-year college or university; and three to four years related experience and/or training specifically in the healthcare field; or equivalent combination of education and experience. Legal or dental background a strong plus.

Computer Skills:

Proficient in Microsoft Office programs and ability to type at least 55 wpm

Other Skills:

Demonstrated ability to handle multiple projects and details simultaneously. Requires self-direction, tact, diplomacy and a clear, courteous and professional manner when dealing with the co-workers and public. Must demonstrate effective written and verbal communication skills and the ability to work cooperatively with staff and clients.

Apply Now

Position Title:

Report Analyst

Reports To:

Director, Reporting Services

FLSA Status:

Exempt

Summary:

A Report Analyst determines report requirements, identifies target data, builds/maintains appropriate data model, establishes/maintains data transformations, creates/modifies required queries, creates/modifies report presentation, verifies report accuracy, delivers the finished report, documents report process and maintains the reporting schedule.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Utilizes the Ingenix tool suite to create: provider directories, Geo Access reports and disruption reports

Designs, develops and supports ad hoc reports using reporting tools

Analyzes and develops Oracle PL/SQL to retrieve the appropriate data when necessary

Interfaces with customers through the life cycle of the report request

Documents report fabrication procedures for quality assurance

Revises report queries for optimal performance

Implements safeguards to validate accuracy of report results

Recommends establishment of new or modified reporting methods and procedures to improve report content and completeness of information.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

4-year degree in Computer Science from College or University or equivalent related experience.

Computer Skills:

Ingenix and GeoAccess/GeoNetwork, Oracle PL/SQL, ETL, Data Modeling, Data Warehouse/Data Mart, Microsoft Access, Excel. OBIEE a strong plus.

Other Skills:

Highly motivated and seeks out opportunities to improve existing processes. Demonstrates expertise in a variety of the field's concepts, practices, and procedures. Superior organizational skills, attention to detail, and ability to prioritize and manage multiple tasks. Knowledge of dental billing/claims, managed health care, health insurance claims a strong plus.

Apply Now

Position Title:

Staff Accountant

Reports To:

Treasurer

FLSA Status:

Exempt

Summary:

Various accounting functions in support of the Accounting Department.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Monitors cash daily and makes transfer recommendations based upon company’s cash flow needs.

Completes daily internal transfers.

Updates ACH spreadsheets and ensures accurate booking of all ACH transactions.

Handle Medicaid/Medicare capitation payment process.

Processes IPA and HPLX of NJ Dental Expense.

Processes MSO payments to Healthplex.

Ensures all correct IPA rates are consistent throughout departments - Accounting, Billing and Government Services.

Create and maintain numerous IPA analysis spreadsheets.

Performs bank reconciliations for all IPA accounts.

Performs all accounting functions for Healthplex Scholarship.

Responsible for maintaining Insurance Policies.

Corporate Accounts Payable on First and 15th of each Month.

Maintain Company informational spreadsheets including but not limited to Auto, Gas Cards and Recurring Expenses.

Prepares IPA, HPLX of NJ and HPLX of CT monthly financials for review by Accounting Manager.

Responsible for compiling financial data to support general ledger activity used in Quarterly and Year End Audits.

Responsible for HPLX of NJ ODS Quarterly Filing (NJ Liquidity).

Backup for Fixed Assets, Prepaid & Unexpired Expense Analyses.

Backup for Insured Companies Direct Deposit.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

Bachelor’s Degree (B. A.) from four-year college plus (2-4) years related experience and/or training; or equivalent combination of education and experience.

Computer Skills:

Proficiency in Navision, Oracle and Microsoft Software programs – Word, Excel, Outlook.

Other Skills:

Familiar with a variety of the field's concepts, practices, and procedures. Works under immediate supervision, performs a variety of accounting tasks.

Apply Now

Position Title:

Web Application Developer

Reports To:

Director of Information Technology

FLSA Status:

Exempt

Summary:

A Web Application Developer designs critical components of internal and external web applications to achieve project goals and deliverables. Individual must be extremely well-rounded with respect to database, back-end and front end abilities. Duties also include testing, debugging and application support.

Essential Duties and Responsibilities:

Include the following. Position Description may change as business conditions change.

Designs/develops/implements forward thinking technical solutions that meet requested need as well as facilitate future enhancements.

Implement vendor supplied applications and design/develop interfaces from internal systems to interact with accordingly.

Gathers requirements from users, creates specifications and develops code.

Designs and writes codes to support existing applications.

Provides technical recommendations to help with solving business problems.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

4-year degree from College or University plus 7 - 10 years related experience.

Computer Skills:

• Oracle 10g/11g with working knowledge of PL/SQL
• Tomcat, Oracle Application Server or WebLogic Application Server experience required
• Working knowledge of Open Source Projects (Spring, Pentaho, SVN)
• Back Office Web App experience (Document Generation, Imaging, etc.)
• Document Generation (Bottomline, Docucorp) experience a plus
• Strong communication and interpersonal skills
• Highly Motivated/Self-Starter

Other Skills:

Demonstrates expertise in a variety of the field's concepts, practices, and procedures. Relies on extensive experience and judgment to plan and accomplish goals. Be able to perform a variety of tasks. May provide consultation on complex projects and is considered to be the top level contributor/specialist. A wide degree of creativity and latitude is expected.

Apply Now