RCM Insurance Specialist

ADVANCED DENTAL BRANDS — REVENUE CYCLE MANAGEMENT

RCM Insurance Specialist

Revenue Cycle Management | Reports to: RCM Insurance Manager

FLSA Classification

Exempt

Job Level

Specialist

Travel Required

Minimal

Department

Revenue Cycle Management

Reports To

RCM Insurance Manager

Position Summary

The RCM Insurance Specialist verifies insurance eligibility for all scheduled patient appointments, builds and maintains insurance plans in Denticon, performs fee schedule maintenance, manages payer portal access via Zkeep, and ensures Denticon insurance ledger integrity. This role is the front-line contributor to ADB's clean claim foundation — accurate verification and plan builds directly prevent downstream billing errors.

Key Responsibilities

• Insurance Verification: Verify insurance benefits for all assigned scheduled appointments 48–72 hours in advance; confirm active coverage, deductibles, remaining maximums, co-pays, frequency limitations, waiting periods, and missing tooth clauses.
• Air Pay Workflow Execution: Process daily verification assignments in Air Pay; review AI-generated eligibility results for accuracy; flag exceptions and incomplete verifications for manual follow-up; enter verified benefit data in Denticon.
• Denticon Insurance Plan Builds: Create and maintain insurance plans in Denticon for new payers and plan changes; configure carrier information, fee schedule assignments, benefit tables, coverage percentages, frequency limitations, and missing tooth clauses.
• Exception Handling: Resolve eligibility exceptions including inactive coverage, payer discrepancies, mid-year plan changes, and COB conflicts; escalate unresolvable issues to the Insurance Manager.
• Payer Portal Utilization and Maintenance: Access payer web portals via Zkeep credentials for manual eligibility verification when Air Pay results are unavailable; maintain current portal access and document verification findings in Denticon.
• Plan Maintenance: Audit and update existing Denticon insurance plans when payer fee schedules change, benefit tables expire, or plan information is found to be inaccurate; flag corrections to the Insurance Manager.
• Fee Schedule Maintenance: Load and maintain accurate contracted fee schedules in Denticon for all active payers as directed by the Insurance Manager; verify fee schedule assignments on new and updated plans.
• Office Communication: Communicate verification results, benefit limitations, and plan setup details to office teams prior to appointments; respond to coverage and plan questions from office staff.
• Jira Ticketing: Submit Jira tickets for Air Pay errors, payer portal access issues, plan build questions, and fee schedule discrepancies requiring Insurance Manager review.
• Denticon Ledger Integrity: Identify and flag insurance-related ledger errors in Denticon including misapplied plan benefits, incorrect fee schedule postings, and unresolved eligibility discrepancies; escalate to the Insurance Manager for resolution.

Denticon System Proficiency Required

Candidates will be assessed on the following Denticon competencies during the interview process.

• Insurance plan build: carrier setup, fee schedule assignment, benefit table configuration, coverage percentages, frequency limitations, and missing tooth clause entry in Denticon
• Fee schedule loading and maintenance: entering and verifying contracted rates per payer in Denticon
• Patient insurance record entry: linking verified plans to patient records and updating benefit information prior to appointments
• Eligibility verification documentation within the Denticon insurance module
• Plan audit: identifying duplicate plans, stale benefit tables, and incorrect fee schedule assignments
• Insurance ledger review: flagging misapplied benefits and incorrect fee schedule postings

Vendor Systems & Tools

This role interacts with the following ADB vendor systems. Proficiency expectations are noted per vendor.

Vendor

System Function

Role-Specific Tasks

Denticon

Practice Management Software

Primary platform for plan builds, benefit entry, fee schedule maintenance, eligibility documentation, and insurance ledger review.

Air Pay

Insurance verification software

Daily verification tool: process IV queue, review AI eligibility results, handle exceptions, and document findings in Denticon.

Zkeep

Username/Password Manager

Access and maintain payer portal credentials via Zkeep for manual eligibility verification; follow team protocols for credential security and updates.

DXC

Electronic Claims Warehouse

Reference DXC payer directories for EFT/ERA status; coordinate new payer setup questions with the Insurance Manager.

Jira

Ticketing software

Submit Jira tickets for Air Pay errors, Zkeep access issues, plan build questions, and fee schedule discrepancies.

Required Qualifications

• 1–3 years of dental insurance verification or plan build experience
• Working knowledge of Denticon insurance module required; plan build experience strongly preferred
• Understanding of dental benefit structures: deductibles, maximums, co-pays, frequency limitations, and coverage percentages
• Experience using payer web portals for manual eligibility verification
• Strong attention to detail; ability to manage high daily verification and plan build volumes
• High school diploma or equivalent required; dental billing coursework preferred

Preferred Qualifications

• Experience with Air Pay or similar AI-assisted IV platform
• Familiarity with Zkeep or equivalent credential management tool
• DSO multi-office dental environment experience

Advanced Dental Brands is an equal opportunity employer. This job description is not exhaustive and may be updated at management discretion.