• Conduct initial and ongoing interviews with claimants • Obtain and review medical records • Make timely and ethical claim determinations • Communicate with claimants, employers, and various medical professionals • Collaborate with fellow case managers, nursing case managers, and consulting physicians • Review complex medical records and leverage tools and resources for decision making • Complete accurate financial calculations consistent with company and state guidelines • Provide exceptional customer service and proactively recognize customer needs

Role Description Vista Robles Dental Group is seeking a detail-oriented and dedicated Claims Processing Specialist to join our team in the Health, Wellness, and Fitness industry. This role plays a vital part in ensuring accurate and timely processing of dental insurance claims, helping our patients receive the benefits they deserve while supporting the smooth operation of our practice. As a Claims Processing Specialist, you will be at the forefront of managing insurance documentation, verifying coverage details, and collaborating closely with insurance providers. If you have a passion for precision, excellent communication skills, and a commitment to patient care, this opportunity is for you. - Prepare, review, and submit insurance claims in compliance with company policies and insurance regulations. - Verify insurance benefits and eligibility through various insurance portals and direct communication. - Follow up on unpaid or denied claims, identifying issues and working toward resolution. - Maintain accurate records of claims status, patient information, and correspondence with insurance carriers. - Assist with billing inquiries related to insurance claims and provide support to patients as needed. - Stay current with changes in dental insurance policies, coding, and industry best practices. - Collaborate with internal teams to improve claims processing workflows and accuracy. Qualifications - High school diploma or equivalent required; Associate’s degree or certification in medical/dental billing or related field preferred. - Minimum of 2 years experience in dental or medical claims processing or billing. - Strong knowledge of dental insurance plans, terminology, and claim submission procedures. - Familiarity with dental billing software and electronic claims submission platforms. - Excellent attention to detail and organizational skills. - Effective communication skills, both written and verbal, with the ability to interact professionally with patients and insurance representatives. - Ability to manage multiple tasks and prioritize in a fast-paced environment. - Proficiency in MS Office applications, especially Excel and Outlook. Requirements - Efficiently process and submit dental insurance claims with accuracy and attention to detail. - Verify patient insurance coverage and eligibility to facilitate seamless billing. - Collaborate with insurance companies to resolve claim discrepancies and denials promptly. - Maintain organized records and documentation related to claims processing. - Support the billing and administrative teams to ensure timely reimbursement and patient satisfaction. - Effective communication skills, both written and verbal, with the ability to interact professionally with patients and insurance representatives. - Ability to manage multiple tasks and prioritize in a fast-paced environment. - Proficiency in MS Office applications, especially Excel and Outlook. Company Description

• Manage claim intake, review, and communication across both digital and paper channels. • Verify eligibility, analyze coverage details, and adjudicate supplemental insurance claims. • Complete the full payment process, including distribution, authorization, and lost‑check resolution. • Apply claim management strategies to ensure accurate payments and appropriate financial outcomes. • Participate in continuous improvement efforts by identifying issues, sharing customer insights, and supporting workflow enhancements.

Role Description The Claims Review Representative 3 makes appropriate claim decisions based on strong knowledge of claims procedures, contract provisions, and state and federal legislation. The Claims Review Representative 3 performs advanced administrative, operational, and customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills. Where you Come In: - Partners with professional staff on pre-screening review by applying guidance and making appropriate decisions, which may include interpretation of provider information or data. - Decisions typically focus on methods, tactics, and processes for completing administrative tasks/projects. - Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniques. - Works under limited guidance due to previous experience and breadth and depth of knowledge of claims processes. Qualifications - Strong and proven experience with processing and adjudicating medical claims. - CAS, CIS/CISpro experience. - Working knowledge of computers or a demonstrated technical aptitude. - Ability to quickly learn new systems. - Ability to manage and prioritize tasks based on business need. - Remote position: 40 hours, 8 hours/day, 5 days per week (Monday-Friday). Occasional overtime may be required. - Due to contractual requirements, this position is not permitted to perform work in Puerto Rico, Alaska, or Hawaii. Requirements - Knowledge of Humana internal systems. - MTV experience. - Knowledge with CPT and ICD9 terminology/codes. - Proficiency in Microsoft Office applications including Word, Excel, and Outlook. Benefits - Benefits starting day 1 of employment. - Competitive 401k match. - Generous Paid Time Off accrual. - Tuition Reimbursement. - Parent Leave. Work at Home Requirements - Self-provided internet service must meet the following criteria: - Minimum download speed of 25 Mbps and upload speed of 10 Mbps recommended; wireless, wired cable, or DSL connection suggested. - Satellite, cellular, and microwave connections can be used only if approved by leadership. - Associates in California, Illinois, Montana, or South Dakota will receive a bi-weekly payment for their internet expense. - Humana will provide telephone equipment appropriate to meet business requirements. - Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Interview Format As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. Travel While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full-time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job-related skills, knowledge, experience, education, certifications, etc. $44,900 - $60,200 per year Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides: - Medical, dental, and vision benefits. - 401(k) retirement savings plan. - Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave). - Short-term and long-term disability. - Life insurance and many other opportunities. Application Deadline 05-21-2026 Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements.