Reviewing Dentist

Guardian Life Insurance

About The Position

The Reviewing Dentist for appeal claims is a licensed dental professional responsible for completing clinical reviews of dental claim appeals. The primary goal is to determine benefit assignment in accordance with Guardian clinical guideline criteria, focusing on benefit determination rather than treatment recommendations. This role ensures consistent and fair application of dental policy and includes responsibilities for peer-to-peer and provider outreach calls. The position is part-time, with a schedule of 24 hours per week, and reports to the Assistant Dental Director.

Requirements

DDS or DMD from an accredited dental school.
Active, unrestricted dental license in at least one U.S. state.
Minimum 5+ years of clinical dental experience.
Prior experience in dental claims clinical review.
Ability to render sound clinical decisions based on submitted documentation, clinical criteria, and industry standards.
Strong written and verbal communication skills, including peer-to-peer communications via phone and email.

Nice To Haves

Utilization review, clinical appeals, managed care, or similar experience preferred.

Responsibilities

Independently review appealed claims and clinical documentation.
Apply clinical criteria, dental policy, and benchmarks to ensure consistent, defensible decisions.
Document clear clinical rationale to support decisions, compliance, and audits.
Escalate cases as needed to the Dental Director/leadership.
Communicate openly, demonstrate self-awareness, and incorporate feedback.
Participate in monthly updates, quarterly IRR exercises, and required calibration sessions.
Support implementation of new review policies/criteria as directed.
Meet production, accuracy, and performance standards.
Conduct peer-to-peer communications with treating providers (phone and/or written) to explain documentation-based clinical determinations.
Communicate decisions clearly and professionally, with a focus on transparency and provider understanding.
Support positive provider relationships through thoughtful, clinically grounded communication.
Conduct provider outreach calls to request missing documentation and/or communicate review outcomes.
Partner, as needed, with an external clinical review vendor to align documentation standards, clinical interpretation, and review quality.
Collaborate with Dental Claims, Network, Product, Compliance, and Quality partners to support clinical operations.
Provide clinical input on appeal trends, documentation gaps, and process improvement opportunities.