Clinical Reviewer

Delta Dental of Arkansas•Sherwood, AR

About The Position

The Clinical Reviewer performs first-level clinical review of claims and pre-treatment estimates using established Delta Dental of Arkansas policies, clinical guidelines, contractual requirements, documentation standards, and delegated authority. The Clinical Reviewer may approve a claim when established requirements are met, but may not deny a claim. Claims that cannot be approved or that may result in an adverse benefit determination are referred to a Dental Consultant or other designated authority for final determination. The role also supports provider communication, accurate and timely workflow, issue identification, and continuous improvement.

Requirements

Five years of related experience in a clinical dental office, dental claims, clinical review, utilization management, or a comparable dental environment. A suitable combination of education, training, certification, and experience may be considered.
Working knowledge of ADA CDT coding, dental terminology, dental procedures, and common clinical documentation.
Ability to review and interpret radiographs, charting, narratives, treatment records, and claim history at the level required for assigned responsibilities.
Strong analytical, organizational, communication, customer service, and problem-solving skills.
Collaborative mindset with the ability to contribute effectively in a team setting.
Ability to prioritize work, meet deadlines, exercise sound judgment, and work with minimal supervision.
Proficiency with Microsoft Office and the ability to learn claims-processing and related systems.

Nice To Haves

Active Registered Dental Hygienist license in good standing.
Dental assisting or other relevant clinical dental credential.
Prior dental claims review, utilization management, clinical review, or dental insurance experience.

Responsibilities

Review assigned claims and pre-treatment estimates requiring first-level clinical evaluation and approve claims that meet established clinical, contractual, processing, and documentation requirements.
Refer claims that cannot be approved, including claims that may result in denial or another adverse benefit determination, to a Dental Consultant or other designated authority. The Clinical Reviewer does not deny claims.
Evaluate radiographs, charting, narratives, treatment records, claim history, provider fees, and other supporting documentation using clinical knowledge, experience, precedent, processing policies, and evidence-based guidelines.
Determine when additional documentation or higher-level clinical review is required and document review findings and processing instructions clearly in the claims system.
Apply ADA CDT coding knowledge, dental terminology, clinical documentation standards, DDPA policies, DDAR procedures, and applicable contractual provisions consistently.
Meet established quality, productivity, accuracy, and turnaround expectations and manage assigned work in accordance with team priorities.
Participate in calibration meetings, training, quality reviews, and continuing education and apply resulting guidance consistently.
Identify and escalate unusual practice patterns, utilization trends, potential fraud, waste, or abuse concerns, documentation issues, policy gaps, or recurrent processing problems through established channels.
Serve as a resource to internal staff regarding dental terminology, procedures, coding, documentation, and clinical review requirements within the scope of the role.
Collaborate with the Lead Clinical Reviewer, Dental Consultants, Claims, Professional Relations, and other departments to support accurate and efficient claim processing.
Represent Delta Dental of Arkansas professionally in communications with participating providers and support constructive provider relationships.
Comply with HIPAA, confidentiality, organizational policies, and all applicable legal and regulatory requirements.
Perform other related duties as assigned.
Communicate critical issues requiring immediate attention as soon as practicable and no later than the same business day.
Escalate material quality, compliance, provider, operational, or workflow concerns within one business day of identification.
Raise barriers that may affect assigned turnaround or accuracy promptly and before deadlines are missed whenever reasonably possible.
When reporting a problem, provide relevant facts and a recommended next step when feasible.