Clinical Research & Escalation Specialist

NCD•Dallas, TX

About The Position

This position researches and resolves negative online reviews, escalated claims issues, and formal member complaints in a timely and effective manner. The specialist reviews clinical details of escalated dental and vision claims—including procedure coding, clinical documentation, and carrier clinical or consultant review determinations—to verify whether outcomes were applied correctly and explain them clearly to members. The role requires strong research, problem-solving, and communication skills, along with working knowledge of dental and clinical claim concepts. The specialist works with members, carriers, provider offices, and internal teams to resolve complex concerns, support customer satisfaction, and help maintain and improve the company’s reputation.

Requirements

Bachelor’s degree in business, communications, or a related field, or equivalent work experience.
At least 3 years of customer service experience focused on research, problem-solving, and issue resolution.
Working knowledge of dental terminology and CDT procedure coding.
Familiarity with clinical claim-adjudication concepts, including dental necessity, frequency and age limitations, waiting periods, and missing-tooth provisions.
Experience reviewing clinical documentation, dental records, radiographs, or EOBs.
Ability to interpret clinical denial rationale and explain it to members in clear, non-technical language.
Strong analytical and research skills, including the ability to identify patterns and root causes in complex issues.
Excellent verbal and written communication skills, with empathy, professionalism, and active listening.
Ability to collaborate with cross-functional teams and build positive relationships.
Proficiency in product knowledge, CRM systems, and standard office software, including Microsoft Office Suite and Google Workspace.
Strong organizational and time-management skills, including the ability to prioritize tasks and manage multiple projects.
Commitment to exceptional customer service and maintaining a positive company reputation.

Nice To Haves

Dental, vision, or health insurance claims experience.
Dental coding or clinical certification, such as Certified Dental Coder (CDC), RDA/CDA, or a claims/coding certification.

Responsibilities

Monitor and review customer feedback, complaints, and negative reviews across online platforms, social media, review websites, and customer support channels.
Research complex complaints and escalated claims, identify patterns and root causes, and determine potential resolutions.
Review clinical details of escalated and denied dental and vision claims, including CDT codes, tooth- and quadrant-level details, clinical narratives, radiographs, and EOBs, to verify claim outcomes.
Interpret carrier clinical and consultant claim-review determinations and explain denial rationale to members in clear, empathetic, plain language.
Coordinate with carrier clinical reviewers, dental consultants, and provider offices to obtain records, radiographs, narratives, and pre-authorization documentation.
Evaluate coordination of benefits at the procedure level and identify clinical denial patterns that may indicate systemic issues or regulatory complaint risk.
Collaborate with MC Training, Engineering, and Sales and Marketing to gather information and develop solutions for member issues.
Resolve escalated member issues professionally and promptly, supporting customer satisfaction and the company’s brand and image.
Communicate with customers by email, phone, text, and online review platforms to address concerns, provide updates, and resolve issues.
Document interactions, findings, and resolutions in the CRM system and maintain accurate records.
Support fraud, waste, and abuse review through clinical claim and provider-signal analysis, including case documentation and referral preparation.
Identify process improvements and recommend changes to enhance the member experience.
Assist with developing and maintaining departmental SOPs and best practices.
Participate in ongoing training and development to stay current on industry trends, best practices, and company policies.
Perform additional tasks and duties as assigned by management.