Senior Dental Benefits Specialist

GEHA Health

. Ensure second-level appeal documentation is accurate, complete, defensible, and consistent with plan provisions, benefit policies, and clinical appropriateness criteria .

Posted 10/5/2026full-timeRemote • Kansas • United StatesSenior💰 $63,329 - $80,115 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in dental claims review, benefit administration, and clinical review coordination, with a strong focus on accuracy, compliance, and effective communication. Proficient in analyzing complex dental claims and appeals while maintaining organized and audit-ready documentation.

Highest-signal resume keywords

Dental Claims ReviewCDT Coding ExpertiseClinical Review CoordinationAudit Findings ReportingBenefit Administration

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Dental Benefit AdministrationClaims Adjudication LogicCoding Accuracy EvaluationClinical Appropriateness Criteria ApplicationAppeal Documentation OwnershipAudit Scope DeterminationDenial Reason IdentificationOrganized Case Summaries PreparationTimely Determinations TrackingCross-Functional Collaboration

Soft Skills

Analytical SkillsAttention to DetailWritten CommunicationIndependent JudgmentDeadline-Driven

Tools & Technologies

Microsoft Office Suite

Certifications & Qualifications

Dental Hygiene CertificationRDH or Equivalent Licensure

Industry Keywords

Dental ClaimsManaged CareBenefit ProvisionsFEDVIPFEHBClinical Review VendorTPAHealth PlanBilling PracticesMember PHI/HIPAA Compliance

About the role

Key responsibilities & impact

Ensure second-level appeal documentation is accurate, complete, defensible, and consistent with plan provisions, benefit policies, and clinical appropriateness criteria
Independently determine documentation sufficiency, need for additional clinical review, and whether case records support final determinations
Own the end-to-end clinical review pathway between G.E.H.A.'s TPA and clinical review vendor
Prepare organized case summaries and supporting documentation for timely determinations
Track appeal status, review rationale, and outcomes within established turnaround standards
Review determination letters and correspondence for accuracy and completeness
Maintain organized, audit-ready appeal case files
Identify appeal volume, denial reason, and determination outcome trends for the Manager, Dental Product
Serve as escalation point for complex or contested appeal documentation questions
Conduct random and directed post-payment claims audits
Review paid dental claims against plan provisions, CDT coding standards, and benefit limitations
Identify overpayments, billing errors, coding irregularities, and potentially improper payments
Prepare clear audit findings reports with irregularity details, dollar amounts, and supporting rationale
Maintain audit records and tracking logs
Identify systemic billing patterns and recurring coding issues
Determine audit scope and sampling approach for directed reviews
Serve as G.E.H.A.'s internal dental subject matter expert on benefit interpretation, CDT coding, claim adjudication logic, and plan provisions
Support benefit policy interpretation, OPM filings, benefit design reviews, member escalations, and dental-specific reviews
Provide guidance to internal partners and TPA staff on dental benefit provisions and CDT coding standards
Review member-facing dental education content for clinical and benefit accuracy
Assist with updating educational materials in line with clinical guidelines, plan provisions, regulatory requirements, and communication standards

Requirements

What you’ll need

Associate's or Bachelor's degree in Dental Hygiene, Health Administration, or a related clinical or health field preferred
Additional years of qualifying relevant work experience may be considered in lieu of formal education
Dental clinical training, certification, or licensure (RDH or equivalent) strongly preferred; equivalent applied dental clinical knowledge gained through sustained dental claims, appeals, or utilization review practice will be considered
Minimum of 5 years of experience in dental claims review, dental benefits administration, or dental appeals processing in a health plan or managed care environment
Demonstrated independent ownership of appeal documentation, clinical review coordination, or claims audit work
Advanced working expertise in dental benefit administration, CDT coding, dental claims adjudication, coordination of benefits, dental benefit structures, and common billing practices
Direct experience supporting appeal documentation, coordinating clinical reviews, or conducting claim audits in a dental insurance or managed dental care setting required
Ability to independently evaluate coding accuracy, benefit application, claim adjudication logic, and payment appropriateness in complex dental claims and appeal scenarios
Ability to exercise independent judgment and work without routine supervision
Ability to explain benefit, coding, and adjudication reasoning clearly to non-dental colleagues and external partners
Sound analytical and clinical reasoning skills
Excellent written communication skills
Meticulous attention to detail and a quality-first approach
Organized and deadline-driven; able to manage concurrent appeals and audit assignments
Ability to work effectively with cross-functional partners, the TPA, and the clinical review vendor
Proficiency in Microsoft Office Suite
Familiarity with FEDVIP, FEHB, or federally regulated dental benefit programs a plus
Experience applying clinical appropriateness criteria or benefit plan provisions preferred
Experience reviewing written determination letters or preparing audit findings reports preferred
Experience serving as a dental subject matter resource or working directly with a TPA or clinical review vendor strongly preferred
Ability to provide non-cellular high-speed internet service such as fiber, DSL, or cable modem for a home office
Minimum internet speed of 30 Mbps download and 5 Mbps upload
Latency response time lower than 80 ms
Hotspots, satellite, and wireless internet service are not allowed
Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information