Sr. Dental Benefits Specialist

Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits that millions of federal employees and retirees, military retirees and their families have counted on since 1937. Offering one of the largest health and dental benefit provider networks available to federal employees in the United States, G.E.H.A empowers health and wellness by meeting its members where they are, when they need care.

G.E.H.A has one mission: To empower federal workers to be healthy and well.

The Senior Dental Benefits Specialist is responsible for second-level appeal documentation integrity, clinical review coordination between G.E.H.A's third-party administrator (TPA) and clinical review vendor, and post-payment claims audits for G.E.H.A's dental programs. This role serves as G.E.H.A's internal dental subject matter expert for benefit interpretation, CDT coding, claims accuracy, and appeal documentation defensibility.

Operating as a senior individual contributor within a federally regulated dental benefits program, the Specialist independently determines documentation sufficiency, identifies when additional clinical review or policy interpretation is required, defines the scope of directed claim reviews, and prepares defensible appeal and audit findings without routine review. The role ensures appeal files, determination records, and audit findings are complete, objective, and audit-ready for internal review, OPM review, or federal audit.

SKILLS

Duties & Responsibilities

Second-Level Appeal Documentation & Clinical Review Ownership

• Ensure second-level appeal documentation is accurate, complete, defensible, and consistent with G.E.H.A’s plan provisions, benefit policies, and clinical appropriateness criteria; independently determine whether documentation is sufficient, whether additional clinical review is required, and whether the case record supports the final determination.

• Own the end-to-end clinical review pathway between G.E.H.A's third-party administrator (TPA) and the clinical review vendor, providing a well-organized case summary and complete supporting documentation to support timely, well-informed determinations, and holding both parties accountable to established turnaround standards.

• Ensure all appeal documentation and clinical review coordination are completed within established internal turnaround standards, maintaining accurate tracking and documentation of case status, review rationale, and outcome for every case.

• Review determination letters and supporting correspondence for accuracy and completeness, ensuring the outcome, rationale, and any applicable next steps are clearly documented for the member or provider.

• Maintain organized appeal case files in accordance with G.E.H.A's documentation standards, ensuring records are audit-ready at all times.

• Identify patterns or trends in appeal volumes, denial reasons, or determination outcomes and surface findings to the Manager, Dental Product for strategic or operational action.

• Serve as the escalation point for complex or contested appeal documentation questions, determining when additional clinical input or policy interpretation is required.

Post-Payment Claims Audit & Payment Accuracy

• Conduct post-payment claims audits on a random basis and as directed, reviewing paid dental claims against G.E.H.A's plan provisions, CDT coding standards, and benefit limitations to identify overpayments, billing errors, or coding irregularities.

• Apply independent analytical judgment to CDT codes, dental benefit structures, and common billing patterns to evaluate claim accuracy and flag potentially improper payments with clear, well-documented findings.

• Prepare audit findings reports that are complete, clearly written, and sufficient for appropriate operational follow-up, including the nature of the irregularity, the dollar amount at issue, and supporting rationale.

• Maintain audit records and tracking logs that document scope, findings, and disposition of each audit in a consistent, organized format.

• Identify systemic billing patterns or recurring coding issues across audit samples and report findings to the Manager, Dental Product, supporting broader program integrity efforts.

• Determine audit scope and sampling approach for directed reviews, selecting claims for examination based on risk indicators, utilization patterns, and prior findings.

Dental Subject Matter Expert Authority

• Serve as G.E.H.A's designated internal dental subject matter expert, answering questions related to dental benefit interpretation, CDT coding, claim adjudication logic, and plan provisions.

• Support the Manager, Dental Product with benefit policy interpretation questions that arise during OPM filings, benefit design reviews, or member escalations requiring dental-specific knowledge.

• Support dental-specific reviews by providing SME input on coding, benefit applicability, and claims accuracy questions that require dental subject matter expertise.

• Contribute dental expertise to team discussions on benefit design, policy updates, or member communication reviews when clinical accuracy is a consideration.

• Provide guidance to internal partners and, where appropriate, to TPA staff on correct application of dental benefit provisions and CDT coding standards.

Member Education — Clinical Accuracy Review

• Review member-facing dental education content for clinical and benefit accuracy, including oral health articles, benefit explainers, and preventive care materials, ensuring alignment with plan provisions and current clinical guidance.

• Assist with reviewing and updating educational materials to ensure alignment with current clinical guidelines, benefit plan provisions, regulatory requirements, and organizational communication standards.

Knowledge, Skills, and Abilities

• 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.

• Requires a 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, including 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, with the demonstrated ability to independently evaluate coding accuracy, benefit application, claim adjudication logic, and payment appropriateness in complex dental claims and appeal scenarios.

• Direct experience supporting appeal documentation, coordinating clinical reviews, or conducting claim audits in a dental insurance or managed dental care setting required.

• Exercises independent judgment on documentation sufficiency, coding accuracy, and claims integrity, working without routine supervision and escalating only matters requiring policy or clinical determination authority.

• Credible as a dental subject matter resource; able to explain benefit, coding, and adjudication reasoning clearly to non-dental colleagues and external partners.

• Sound analytical and clinical reasoning skills; able to evaluate complex appeal cases objectively and ensure documentation and clinical review coordination are complete and well-supported.

• Excellent written communication skills: reviews appeal documentation and determination letters for accuracy and produces clear, professionally written audit findings reports that accurately convey rationale and outcome.

• Meticulous attention to detail with a quality-first approach; understands that accuracy in appeals and audit work has direct financial and regulatory consequences.

• Organized and deadline-driven; manages a caseload of concurrent appeals and audit assignments without losing accuracy or timeliness.

• Collaborative and professional; works effectively with cross-functional partners, the TPA, and the clinical review vendor to coordinate reviews and maintain documentation integrity.

• Proficiency in Microsoft Office Suite; experience with claims review systems or case management tools preferred.

Preferred Qualifications

• Familiarity with FEDVIP, FEHB, or federally regulated dental benefit programs a plus.

• Experience applying clinical appropriateness criteria or benefit plan provisions to appeal documentation and clinical review coordination preferred.

• Experience reviewing written determination letters or preparing audit findings reports for member, provider, or internal audiences preferred.

• Experience serving as a dental subject matter resource for non-dental colleagues or working directly with a TPA or clinical review vendor, strongly preferred.

Work-at-home requirements

• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.

• A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.

• Latency (ping) response time lower than 80 ms

• Hotspots, satellite and wireless internet service is NOT allowed for this role.

• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

How we value you

• Competitive pay/salary ranges

• Incentive plan

• Health/Vision/Dental benefits effective day one

• 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution

• Robust employee well-being program

• Paid Time Off

• Personal Community Enrichment Time

• Company-provided Basic Life and AD&D

• Company-provided Short-Term & Long-Term Disability

• Tuition Assistance Program

While this is a remote opportunity, at this time G.E.H.A does not hire employees from U.S. territories or the following states: Alaska, Hawaii, California, Washington, Oregon, Colorado, Wyoming, Montana, New York, Connecticut, Vermont, Pennsylvania, Maine.

Please note that the salary information is a general guideline only. G.E.H.A considers factors such as (but not limited to) scope and responsibilities of the position, candidate’s work experience, education/training, key skills, internal peer equity, as well as, market and business considerations when extending an offer.

The target hiring range for this position is $63,329 - $80,115 USD. At G.E.H.A, the current maximum salary for this role is $89,271 USD. While initial compensation may vary based on experience and qualifications, there is a path to work toward this top rate through performance and continued growth within the organization.

G.E.H.A is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. G.E.H.A will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. We are committed to creating an inclusive environment for all employees.

G.E.H.A is headquartered in Lee's Summit, Missouri, in the Kansas City area. We recognize the importance of balance and flexibility and offer hybrid and work-from-home options for many of our roles.

Originally posted on Himalayas