Job Description

Clinical Review and Education Representative

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. We offer a highly competitive medical, dental and vision plans as well offering a generous 401k match and all employees start accruing vacation and sick time from their very first day. We empower employee development through our tuition reimbursement plan, professional development plans, and employee-led communities. The pay range for this position in Western Washington varies between $46,575 -- $62,963, and for Eastern Washington varies between $45,083 - $60,946. Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza intends to offer the selected candidate a base pay within this range, dependent on job-related, non-discriminatory factors such as experience. Base pay will also be adjusted based on the candidate's geographic location.

Essential Responsibilities include the following:

• 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.

Experience, skills, and education do you need to have to succeed in the position:

The requirements listed below are representative of the knowledge, skill, and/or ability required to successfully perform the essential functions of the position. 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 communica

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