Clinical Review and Education Representative

Delta Dental of Washington•Spokane, WA

13d•$45,083 - $62,963

About The Position

Are you ready to put your dental expertise to work by reviewing claims and supporting clinical teams in delivering accurate and timely benefits decisions? As a Clinical Review and Education Representative, you will review and adjudicate dental claims by evaluating clinical documentation and records such as radiographs, narratives, and chart notes in accordance with group contracts and Delta Dental guidelines, ensuring accuracy, identifying potential fraud or abuse, and collaborating with Dental Consultants, Customer Service, and other internal teams to achieve one call resolution for providers and members. At Delta Dental of Washington our vision is that all people can enjoy good oral and overall health, with no one left behind. We succeed because of a shared commitment to a set of values that guide everything we do – for our customers, for our communities, and for each other. We are Accountable. We lean in with Courage. We stay Curious. We are Inclusive. We act with Integrity.

Requirements

Demonstrated experience as a dental assistant or dental hygienist in a clinical or administrative setting
Proficient knowledge of dental terminology, dental anatomy, dental radiography, and interpretation of periodontal charts
Skilled in navigating and using technical systems and dental claims processing platforms
Ability to accurately review, document, and organize high volumes of claim information with strong attention to detail
Proficient in written and verbal communication for explaining clinical information to internal teams and external providers and office staff
Experience collaborating with cross-functional teams in healthcare or dental operations
Working knowledge of claims adjudication workflows and appeals handling procedures

Responsibilities

Research and review dental claims and supporting clinical documentation and records including radiographs, periodontal charts, intra and extra oral images, narratives, and chart notes to determine benefits based on group contracts and Delta Dental guidelines.
Preview claims and appeals for completeness and accuracy before referring to Dental Consultants for a clinical determination
Review appeals for claims and predeterminations previously denied due to missing information, history violations, or claims processing errors
Participate in regular calibration sessions to ensure consistent application of claim review guidelines
Identify, document, and report suspected fraud, abuse, or unusual practice patterns during claim review
Respond to escalated provider calls from Support Team Representatives and answer clinical questions from Customer Service Representatives to support one call resolution
Represent the department on cross functional teams and committees as assigned