Dental Insurance Verification & Prior Authorization Specialist

POSITION SUMMARY

The Insurance and Benefits Specialist facilitates the dental insurance prior authorizations, pre-treatment estimates, claim denials, appeals, and insurance follow-up to support timely reimbursement and efficient revenue-cycle operations. This position works closely with clinical and administrative teams to ensure procedures are appropriately authorized, claims are submitted accurately, and denied or underpaid claims are resolved promptly and effectively.

KC CARE CULTURE CODE

KC CARE follows a culture code in all we do. Our code determines how we work, treat each other, and move health equity forward. As an employee of KC CARE, you will:

• Put patients first, always
• Treat all people with dignity, respect, and kindness
• Create safe places for others to share their voice; encourage creativity
• Always strive for improvement; keep learning
• Own your work, action, and mistakes – no one is perfect
• Have fun – work should be fun and we want you to have fun at KC CARE

KC CARE CULTURE VALUES

Exceptional Service: We value exceptional service in providing unconditional whole-person care to everyone with the promise of a personalized and affirming experience for patients. We promise to treat internal and external partners with dignity, respect, and kindness to facilitate the opportunity for all to succeed.

Inclusion and Belonging: We value diversity, equity, inclusion, and belonging by focusing on differences that promote creativity and acceptance across the organization. We promise to create a safe environment for individuality to flourish.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Verify dental insurance eligibility, benefits, limitations, exclusions, waiting periods, frequency limitations, and prior authorization requirements before treatment.
• Obtain, prepare, submit, and track dental insurance prior authorizations and pre-treatment estimates to support timely treatment planning and reimbursement.
• Review treatment plans, clinical notes, X-rays, periodontal charts, CDT procedure codes, and other supporting documentation to ensure authorization and claim requirements are met.
• Communicate with dental providers, clinical teams, administrative staff, and patients regarding insurance requirements, authorization status, treatment coverage, and anticipated patient responsibility.
• Monitor prior authorization and pre-treatment estimate status, ensuring timely follow-up with insurance carriers through phone, payer portals, and electronic correspondence.
• Review denied, rejected, and underpaid dental claims to identify denial reasons, payer requirements, coding issues, and opportunities for resolution.
• Research dental insurance policies, clinical guidelines, CDT codes, and payer-specific requirements to determine appropriate claim resolution strategies.
• Prepare and submit corrected claims, reconsiderations, and appeals with accurate clinical, coding, and insurance documentation.
• Interpret EOBs and ERAs to identify payment discrepancies, denial trends, bundling issues, frequency limitations, exclusions, and other non-payment or underpayment concerns.
• Maintain accurate and comprehensive documentation of prior authorizations, denials, appeals, claim follow-up, payer communications, and resolution activities within applicable systems.
• Identify recurring authorization and denial trends and communicate findings to billing, clinical, and administrative teams to support process improvement and reduce avoidable denials.
• Collaborate with dental providers and billing teams to obtain missing documentation, clarify clinical information, and resolve insurance-related issues.
• Monitor established turnaround times, productivity expectations, and follow-up activities to ensure timely completion of assigned authorization and denial workflows.
• Maintain working knowledge of dental insurance plans, payer policies, organizational workflows, CDT coding, dental terminology, and applicable compliance requirements.
• Utilize eClinicalWorks (eCW), dental practice-management systems, insurance portals, and other technology platforms to document and manage insurance-related activities.
• Protect patient confidentiality and maintain compliance with HIPAA, organizational policies, payer requirements, and applicable regulatory standards.
• Assist with other dental insurance, billing, revenue-cycle, and patient financial services activities as assigned.
• Other duties as assigned.

MINIMUM REQUIREMENTS

• High school diploma or equivalent
• Previous experience with dental insurance, insurance verification, prior authorizations, claims, or denials preferred.
• Knowledge of dental terminology and CDT procedure codes.
• Understanding of dental insurance benefits, including limitations, exclusions, waiting periods, and frequency limitations.
• Experience interpreting EOBs/ERAs and identifying claim denial or non-payment reasons.
• Strong written and verbal communication skills, with the ability to communicate effectively with patients, dental offices, and insurance carriers.
• Excellent attention to detail, organization, and follow-through.
• Ability to research insurance requirements, payer policies, and claim issues and determine appropriate resolution.
• Ability to communicate professionally and effectively with insurance carriers and dental offices by phone, portal, and electronic correspondence.
• Experience using dental practice-management software, preferably eClinicalWorks (eCW), and insurance portals preferred.
• Ability to work independently, manage multiple priorities, and meet established turnaround times and productivity expectations.

PREFERRED REQUIREMENTS

· Two or more years of experience in dental insurance and/or dental billing.

· One year experience obtaining and managing dental insurance prior authorizations and pre-treatment estimates.

· Experience reviewing, correcting, and appealing denied dental claims.

· Familiarity with major dental insurance carriers and payer requirements.

· Experience working with CDT procedure codes and dental clinical documentation.

· Experience in a dental office, dental billing company, or dental insurance environment.

WORKING CONDITIONS AND DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Working Conditions

General working conditions are in a healthcare facility. As such, there is a potential exposure to virus, disease, and infection from patients while performing the duties of this job. May experience traumatic situations including psychiatric traumatized and deceased patients. Travel may be expected to community meetings, client homes, or other agencies.

Physical Demands

While performing duties of this job, employees are regularly required to set, walk, and stand; talk and hear; both in person and by telephone; use hands repetitively to finger, handle, feel, or operate standard office or clinical equipment; reach with hands and arms; and occasionally lift up to 20 pounds.

Mental Demands

While performing the duties of this job, employees are regularly required to use written and oral communication skills; read, analyze, and interpret data, information and documents; analyze and solve non-routine and complex problems; use math and mathematical reasoning; observe and interpret situations; learn and apply new information or skills; perform highly detailed work on multiple, concurrent tasks; work under intensive deadlines with frequent interruptions; and interact with others outside of their department.

Duties and responsibilities, as required by business necessity may be added, deleted, or changed at any time at the discretion of management, formally or informally, either verbally or in writing. Scheduling, shift assignments, and location may be changed at any time, as required by business necessity.