Claims Examiner

Claim Processor/Adjustor

Reviewed 9.2025

Delta Dental of Illinois

Job Description

JOB TITLE: Claim Processor/Adjustor

DEPARTMENT: Claims

REPORTS TO: Manager, Claims

PAY STATUS: Non-Exempt

OVERVIEW OF POSITION: The Claim Processor/Adjustor is responsible for providing service to the DDIL client

base through accurate processing of dental claims as well as troubleshooting and resolving all types of dental

claim related inquiries.

DUTIES & RESPONSIBILITIES:

* Investigate and process claims according to established business rules that have failed computer program

edits

* Provide guidance in claims processing requiring advanced technical and dental knowledge

* Meet daily/weekly claim production goals as set by the ITL

* Complete and maintain daily audit production logs

* Accurately completes special projects assigned within specified time frame

* Access EPHI following the current guidelines as established at the company-wide and department levels.

* Maintain regular and punctual attendance

* Perform other job-related duties as assigned (Professional Review, Appeals Review, E-Forms)

* Update ITL or Manager regarding daily status of assigned reports by timeframe established by ITL or

Manager.

* Encouraged to work overtime according to business need.

* Accesses EPHI following the current guidelines as established at the company- wide and department levels.

* Maintains regular attendance and punctuality.

* Performs other job-related duties as assigned.

EXPERIENCE & QUALIFICATIONS:

* Excellent oral and written communications skills. Strong computer keyboard skills. Knowledge of insurance

reimbursement practices, i.e. processing policies, deductibles, maximums, Coordination of Benefits (COB)

and dental terminology.

* Ability to work independently and execute multiple tasks simultaneously

* Excellent attendance and punctuality record.

Claim Processor/Adjustor

Reviewed 9.2025

While not a requirement for the position, a preference is given to those who:

* can speak Spanish fluently, or

* can make diagnostic determinations based on provider claim narratives, dental photos and radiographs

Employee Signature Date