Professional Review Clinical Specialist

DELTA DENTAL OF VIRGINIA • Roanoke, VA

1d • Remote

About The Position

Seeking a Dental Assistant or Hygienist to review claims with submitted diagnostic material to make proper benefit determinations based on group contracts and DeltaUSA and departmental established guidelines/policies. This role is responsible for clearing queues daily and pending claims for additional information. The specialist will also refer claims to dental consultants for review.

Requirements

• Dental Assistant or Dental office manager.
• Knowledge interpreting dental x-rays.
• The ability to follow established procedures with moderate decision-making.
• Extensive computer knowledge/skills.
• Strong interpersonal and communication skills.
• The ability to focus for long periods of time.
• A positive attitude with ability to adapt to change and learn new things.

Responsibilities

• Reviews diagnostic material (i.e. x-rays, periodontal charting, etc.) to determine appropriate benefits.
• Adjudicates claim benefit review requests in a timely manner.
• Refers claims to dental consultant for review when diagnostic materials do not appear to support the procedure requested.
• Follows DeltaUSA guidelines and departmental guidelines/policies for claims processing.
• Works in a team concept with the CCU and other departments within Delta Dental.
• Maintains accuracy and production numbers to meet department expectations.
• Audited to ensure KPI’s are met monthly.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed