The Clinical Review Specialist is responsible for tasks requiring clinical expertise, including clinical claim reviews, prior authorizations, and assessments of potential fraud and abuse. The Specialist also determines the need for escalation of these items and makes referrals to the Dental Consultant team for additional review and expertise as needed.

This person needs to be located out of one of these states: GA, FL, AZ, UT, or TX.

Responsibilities:

• Reads, interprets, and analyzes x-rays, progress notes, and other clinical documentation to determine benefit in accordance with contract language and coverage limits.
• Responds to inquiries from internal and/or external stakeholders regarding clinical claim or prior authorization requests.
• Escalates items to the Dental Consultant team for review as needed; partners with Dental Consultant in the resolution and follow-up of cases.
• Engages with provider offices to obtain necessary information for clinical review and assessment.
• Evaluates provider utilization patterns and maintains provider/facility review suspend flags.
• Participates in process improvement initiatives, projects, policy review, and annual Current Dental Terminology (CDT) review as needed.
• Actively acquires and maintains knowledge of Delta Dental plan designs and effectively applies that knowledge to daily tasks and process improvement initiatives.
• Monitors compliance to Processing Policies by assessing items referred to Clinical Review; provides feedback on policy adherence and flags policies for additional review as needed.

• 3+ years of experience with High School
• 3+ years clinical dental experience and Associates degree or higher in Business Administration or related field preferred. Certificate or higher in Dental Assisting required.
• Working knowledge of claims processing flow and adjudication.
• Understanding of dental procedures, CDT, and related concepts.
• Knowledge of Delta Dental products, policies, claims, eligibility and underwriting guidelines.
• Ability to interpret, develop and ensure adherence to enterprise and departmental policies and procedures.
• Excellent oral and written communication skills.
• Detail-oriented with strong analytical and problem-solving skills.
• Knowledge of Microsoft Office programs, i.e. Word, Excel, Outlook etc.
• Ability to maintain strict confidentiality.
• Excellent customer service skills.

• Competitive base and incentive pay
• 401(k) with robust matching and non-matching contributions
• Rich medical & pharmacy benefits
• 100% employer-paid dental and vision benefits
• Holistic wellbeing program with deep financial incentives
• Generous paid time off plus 12 paid holidays and your birthday off
• Culture of growth and learning: career development; tuition reimbursement; recognition program
• Family support: adoption assistance, fertility treatment, child, elder & pet care assistance
• Social responsibility and volunteer opportunities
• Employee discount program