Benefit Breakdown Specialist

Job description

Job Summary:
The Dental Breakdown Specialist is responsible for obtaining, reviewing, and documenting dental insurance benefit information to support accurate patient scheduling, treatment planning, and financial communication. This position works closely with Dental, Patient Support and Care Coordination, Front Office, Billing, and other departments to ensure dental benefits are accurately interpreted and documented in the electronic medical record (EMR).
Essential Duties and Responsibilities:
• Obtain and review dental insurance benefit information through payer portals, electronic systems, telephone verification, and other approved resources.
• Complete accurate dental benefit breakdowns based on the patient's specific insurance plan and planned services.
• Review eligibility and coverage prior to scheduled dental services in accordance with organizational workflow.
• Identify applicable deductibles, co-insurance, copayments, annual maximums, frequency limitations, age limitations, waiting periods, exclusions, and plan-specific restrictions.
• Review current and used-to-date benefit information when applicable.
• Document benefit information in the designated EMR fields and/or approved systems so that information can be accurately reported and accessed by other team members.
• Ensure breakdowns are completed within established departmental turnaround times.
• Review previously completed breakdowns when needed and update information when insurance coverage or treatment plans change.
• Identify discrepancies or unclear benefit information and escalate to the appropriate payer, supervisor, or department for clarification.
• Provide accurate benefit information to appropriate staff members who assist patients with scheduling, treatment planning, and financial discussions.
• Assist Front Office and Dental staff in understanding insurance benefits and coverage limitations.
• Respond to questions regarding benefit information and assist with resolving discrepancies.
• Communicate professionally, respectfully, and clearly with patients, staff, insurance representatives, and providers when clarification is needed.
• Maintain compliance with all HIPAA and privacy standards
• Maintain compliance with all company policies and procedures
• Other duties as assigned.

Education and/or Work Experience Requirements:
Required:
• High school diploma or equivalent.
• Experience using electronic health records, practice management systems, payer portals, or similar healthcare technology.
• Strong attention to detail and ability to accurately interpret insurance benefit information.
• Strong written and verbal communication skills
• Ability to work independently while also functioning effectively as part of a multidisciplinary team.
• Ability to manage a high volume of work while maintaining accuracy and meeting deadlines.

Preferred:
• Previous experience in an FQHC, community health center, dental practice, or other healthcare setting.
• Knowledge of dental procedure codes and common dental terminology.
• Experience with dental benefit breakdowns or insurance predeterminations.
• Experience with Epic or another electronic medical record/practice management system.
• Experience working with insurance payer portals.

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