Key Responsibilities and Required Skills for Health and Dental Claims Analyst

🎯 Role Definition

The Health and Dental Claims Analyst is responsible for accurate, timely adjudication and lifecycle management of medical and dental claims, ensuring compliance with payer contracts, plan documents and regulatory requirements (including HIPAA). This role investigates claim denials and underpayments, performs complex benefit and eligibility determinations, collaborates with providers and internal teams to resolve disputes, and produces actionable insights to reduce leakage and improve member/provider experience. The ideal candidate combines domain expertise in dental and medical coding (CDT, ICD-10, CPT), strong analytical skills, and proven experience with claims systems and EDI transactions.

📈 Career Progression

Typical Career Path

Entry Point From:

Claims Processor / Claims Specialist (Health or Dental)
Medical/Dental Billing Specialist or Coder
Customer Service Representative in healthcare benefits

Advancement To:

Senior Claims Analyst / Lead Claims Analyst
Claims Operations Supervisor / Manager
Provider Relations Manager
Reimbursement or Revenue Integrity Analyst

Lateral Moves:

Appeals & Grievances Specialist
Utilization Management Coordinator
Network/Provider Contract Analyst

Core Responsibilities

Primary Functions

Review, adjudicate, and process health and dental claims end-to-end, verifying member eligibility, plan benefits, provider details, and fee schedules to ensure accurate reimbursement and compliance with plan rules.
Perform in-depth claim investigations for complex cases, including coordination of benefits (COB), subrogation, coordination with secondary payers, and retroactive coverage adjustments to minimize leakage and recoup overpayments.
Analyze Explanation of Benefits (EOBs), Electronic Remittance Advice (ERA/835), and remittance reports to reconcile payments, identify discrepancies, and initiate corrective actions or recoveries.
Research and resolve claim denials, rejections, and underpayments using payer/provider contract interpretation, claim history review, and appeals/claim adjustment processes to achieve optimal financial and member outcomes.
Interpret dental CDT codes, medical ICD-10 and CPT codes, and apply proper coding logic to determine medical necessity, bundling/unbundling, and appropriate benefit allowances.
Apply contract language and fee schedules to determine allowable amounts, co-payments, co-insurance, deductibles, pre-authorization requirements, and member responsibility, documenting rationale for adjudication decisions.
Manage provider inquiries and disputes by preparing, presenting, and negotiating claim resolutions; provide clear documentation and education to providers on claim determination and billing best practices.
Execute claim re-pricing and manual adjustments when automated engines misapply rules; create detailed audit trails and submit adjustments within SLA targets to preserve auditability and financial accuracy.
Maintain and update claims adjudication rules and configuration requests in coordination with claims systems analysts, ensuring rule logic reflects current plan language, regulatory changes, and negotiated contracts.
Prepare and submit formal appeals and grievance responses with supporting clinical and contractual documentation, following internal escalation protocols and regulatory timelines.
Monitor quality and productivity KPIs including accuracy rate, turnaround time (TAT), denial rate, and recovery dollars; implement continuous improvement actions based on trend analysis and root cause assessments.
Collaborate with clinical staff, medical directors, utilization management, and pharmacy teams to validate clinical necessity and coverage criteria for complex health and dental claims.
Support audits (internal, external, regulatory) by assembling claim files, providing documented justification for decisions, and remediating identified control gaps or operational deficiencies.
Reconcile claims and financial reports with accounting/payables teams to ensure correct posting of claims expense, reserves, and recoveries; escalate material variances and recommend corrective accounting entries as needed.
Extract, clean, and analyze claims datasets to identify patterns (e.g., recurring denials, coding errors, provider billing anomalies) and translate findings into operational initiatives that reduce rework and improve first-pass payment rates.
Configure, test, and validate claims system updates, patches, and new adjudication logic in UAT and production environments; collaborate with IT to ensure quality deployments and rollback plans.
Train and mentor junior claims staff on adjudication best practices, complex case handling, policy interpretation, and effective provider communications to raise team capability and consistency.
Maintain strict confidentiality and compliance with HIPAA and other privacy regulations while handling sensitive member and provider information.
Process and manage subrogation and third-party liability claims by investigating incidents, coordinating with legal and recovery teams, and documenting recoverable amounts and timelines.
Participate in cross-functional projects to implement new products, benefit designs, or provider network changes, providing claims impact analysis and operational readiness input.
Document standard operating procedures (SOPs), knowledge base articles, and decision trees to capture institutional knowledge and support scalable claims operations.

Secondary Functions

Support ad-hoc reporting requests by extracting claim-level data and preparing executive summaries that highlight financial impact, root causes, and recommended remediation steps.
Assist in vendor management activities for clearinghouses, EDI providers, and outsourced claim processing partners; evaluate performance and ensure SLA adherence.
Contribute to rate setting and actuarial discussions by providing claims trend data, utilization metrics, and evidence of historical claim cost drivers.
Participate in cross-training with customer service, enrollment, and provider relations teams to create seamless member and provider experiences around claims inquiries.
Lead or support continuous improvement initiatives such as Lean, Six Sigma, or Kaizen events focused on claims throughput, accuracy, and cost containment.
Maintain up-to-date knowledge of regulatory changes affecting claims adjudication (e.g., changes to parity laws, surprise billing rules, or dental plan mandates) and update policies/procedures accordingly.
Facilitate data validation and reconciliation between claims adjudication systems and downstream reporting/data warehouses to ensure integrity of management dashboards.
Prepare materials and take part in provider education sessions to reduce recurring billing errors and improve claims acceptance rates.
Support pricing and underwriting teams with claim simulations for new benefit designs, including estimated impact on medical/dental spend and member cost-sharing.
Participate in disaster recovery and business continuity planning for claims operations, including backup workflows and prioritization protocols.

Required Skills & Competencies

Hard Skills (Technical)

Claims adjudication expertise for health and dental benefits, including knowledge of CDT (Current Dental Terminology), ICD-10, and CPT coding.
Working knowledge of coordination of benefits (COB), subrogation, and third-party liability handling.
Proficiency with claims systems and EDI transactions (835 ERA/EDI, 837 claims) and common clearinghouse processes.
Experience using industry platforms such as Availity, Change Healthcare, Epic Claims, or comparable claims adjudication and provider portals.
Strong Excel skills (pivot tables, VLOOKUP/XLOOKUP, advanced formulas) and experience using BI tools (Power BI, Tableau) or SQL for claims data extraction and analysis.
Familiarity with payer/provider contracts, fee schedules, medical necessity rules, and prior authorization workflows.
Ability to interpret Explanation of Benefits (EOB), remittance advice (RA), and reconcile payments to claims.
Knowledge of HIPAA privacy and security requirements, regulatory claims timelines, and compliance frameworks.
Experience performing audits, QA reviews, and root cause analysis of claim processing exceptions.
Basic understanding of accounting concepts relevant to claims reserves, recoveries, and financial reconciliation.
Experience configuring and testing adjudication rules in UAT and production environments.
Competency with case management tools and ticketing systems to document and track escalations.

Soft Skills

Exceptional attention to detail with a strong bias for accuracy in adjudication and documentation.
Strong analytical and problem-solving skills with the ability to convert complex claim patterns into operational solutions.
Clear, professional written and verbal communication for interactions with providers, members, vendors, and internal stakeholders.
Customer-focused mindset with empathy and effective negotiation skills when resolving provider or member disputes.
Time management and prioritization skills to balance high-volume claims workload while meeting SLA targets.
Collaborative team player who can work cross-functionally and influence without direct authority.
Adaptability to changing regulations, product designs, and claims system updates.
Sound judgment and ability to escalate complex or legally sensitive matters appropriately.
Coaching and mentoring capability to develop junior claims staff and improve team performance.
Process-oriented mindset with a continuous improvement approach to reduce rework and improve first-pass accuracy.

Education & Experience

Educational Background

Minimum Education:

Associate degree in Health Administration, Business, Dental Hygiene, or related field; or equivalent claims/insurance experience.

Preferred Education:

Bachelor's degree in Health Administration, Healthcare Management, Nursing, Business, or related discipline.

Relevant Fields of Study:

Health Administration
Healthcare Management
Business Administration
Nursing
Dental Hygiene / Dental Assisting
Health Information Management

Experience Requirements

Typical Experience Range: 2 - 5 years of hands-on health and/or dental claims adjudication, appeals, or provider billing experience.

Preferred: 3+ years adjudicating commercial and/or government payer claims with demonstrated experience in dental claims (CDT) and medical coding (ICD-10/CPT), EDI transaction handling, and claims systems configuration.

If you would like, I can tailor this document to a specific seniority level (e.g., Junior, Senior, Lead) or adjust for a particular system (e.g., Availity, Epic) and include suggested interview questions, KPI targets, or a one-page recruiter summary.