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SalaryJOB DESCRIPTION
The Clinical Review Specialist is responsible for tasks requiring clinical expertise, including clinical claim reviews, prior authorizations, and assessments of potential fraud and abuse. The Specialist also determines the need for escalation of these items and makes referrals to the Dental Consultant team for additional review and expertise as needed.
RESPONSIBILITIES
QUALIFICATIONS
ADDITIONAL INFORMATION
Rewards to make you smile! We don't just want to make our customers happy - we want to give our employees a reason to smile, too. Delta Dental's comprehensive benefits package includes:
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
#LI-Remote
ABOUT THE TEAM
At Delta Dental, our success is only as strong as the people who execute it! We take enormous pride in being the nation's most recognized and widely-used provider of dental insurance - and we've come this far by living our core values of innovation, excellence, service and trust. Our vision is to motivate and empower every employee so that we're all inspired to take exceptional care of our customers, providers and ourselves. We believe in integrity, accountability, collaboration, and giving every employee equitable opportunity for their voice to be heard and development to be fostered.
If you're excited about the prospect of transforming the future of health care and growing in your career, join our smile revolution!
To see some of the smiling faces behind Delta Dental and to learn more about what our values and culture look like in action, connect with us on social media: Delta Dental Ins. on Facebook and Instagram, #LifeatDDins on Facebook and Instagram, Delta Dental Ins. on Twitter and Delta Dental Ins. on LinkedIn.
We are part of the Delta Dental Plans Association, a network of companies that provides dental coverage to 74 million people in the U.S. Delta Dental of California, Delta Dental of New York, Inc., Delta Dental of Pennsylvania and Delta Dental Insurance Company, together with our affiliate companies, form one of the nation's largest dental benefits delivery systems, covering 33 million enrollees. All of our companies are members, or affiliates of members, of the Delta Dental Plans Association, a network of 39 Delta Dental companies throughout the country.
Delta Dental is an equal opportunity employer. We are committed to building and maintaining a diverse and inclusive workplace for all employees. Applicants will not be discriminated against because of race, color, religion, creed, national origin, ancestry, citizenship status, sex (including pregnancy), sexual orientation, gender or identity expression, age, disability, marital status, medical status, veteran status or any other status protected under federal, state, or local law. In addition to federal law requirements, Delta Dental complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
Unfortunately, our Delta Dental Enterprise is unable to hire individuals residing in Alaska, North Dakota, Nebraska, Hawaii, Oklahoma, Vermont, Maine, West Virginia, New Hampshire, Wyoming, Puerto Rico or other US Territories at this time.
Proof of eligibility to work in the United States must be provided if selected for hire.
The Clinical Review Specialist is responsible for tasks requiring clinical expertise, including clinical claim reviews, prior authorizations, and assessments of potential fraud and abuse. The Specialist also determines the need for escalation of these items and makes referrals to the Dental Consultant team for additional review and expertise as needed.
RESPONSIBILITIES
- Reads, interprets, and analyzes x-rays, progress notes, and other clinical documentation to determine benefit in accordance with contract language and coverage limits.
- Responds to inquiries from internal and/or external stakeholders regarding clinical claim or prior authorization requests.
- Escalates items to the Dental Consultant team for review as needed; partners with Dental Consultant in the resolution and follow-up of cases.
- Engages with provider offices to obtain necessary information for Clinical Review and assessment.
- Evaluates provider utilization patterns and maintains provider/facility review suspend flags.
- Participates in process improvement initiatives, projects, policy review, and annual Current Dental Terminology (CDT) review as needed.
- Actively acquires and maintains knowledge of Delta Dental plan designs and effectively applies that knowledge to daily tasks and process improvement initiatives.
- Monitors compliance to Processing Policies by assessing items referred to Clinical Review; provides feedback on policy adherence and flags policies for additional review as needed.
QUALIFICATIONS
- 3+ years of experience w/High School
- 3+ years clinical dental experience and Associates degree or higher in Business Administration or related field preferred. Certificate or higher in Dental Assisting required.
- CDA-Certified Dental Assistant. Pref'
- Working knowledge of claims processing flow and adjudication.
- Understanding of dental procedures, CDT, and related concepts.
- Knowledge of Delta Dental products, policies, claims, eligibility and underwriting guidelines.
- Ability to interpret, develop and ensure adherence to enterprise and departmental policies and procedures.
- Excellent oral and written communication skills.
- Detail-oriented with strong analytical and problem-solving skills.
- Knowledge of Microsoft Office programs, i.e. Word, Excel, Outlook etc.
- Ability to maintain strict confidentiality.
- Excellent customer service skills.
Base Pay Information
The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental's assessment of the candidate's knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity. $41,000 - $83,200
ADDITIONAL INFORMATION
Rewards to make you smile! We don't just want to make our customers happy - we want to give our employees a reason to smile, too. Delta Dental's comprehensive benefits package includes:
- Generous paid time off plus 12 holidays and your birthday off!
- Low-cost premium medical insurance options
- 100% paid dental and vision insurance
- Generous 401(k) matching and flat contribution
- Social responsibility and volunteer opportunities, including 16 paid volunteer hours annually
- Employee LiveWell program, focusing on overall employee well-being
- Fertility and diabetes benefits
- Employee discount program: AT&T/Verizon, entertainment, travel, and more!
- Culture of learning: career development and tuition reimbursement
- Career growth: we love promoting from within
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
#LI-Remote
ABOUT THE TEAM
At Delta Dental, our success is only as strong as the people who execute it! We take enormous pride in being the nation's most recognized and widely-used provider of dental insurance - and we've come this far by living our core values of innovation, excellence, service and trust. Our vision is to motivate and empower every employee so that we're all inspired to take exceptional care of our customers, providers and ourselves. We believe in integrity, accountability, collaboration, and giving every employee equitable opportunity for their voice to be heard and development to be fostered.
If you're excited about the prospect of transforming the future of health care and growing in your career, join our smile revolution!
To see some of the smiling faces behind Delta Dental and to learn more about what our values and culture look like in action, connect with us on social media: Delta Dental Ins. on Facebook and Instagram, #LifeatDDins on Facebook and Instagram, Delta Dental Ins. on Twitter and Delta Dental Ins. on LinkedIn.
We are part of the Delta Dental Plans Association, a network of companies that provides dental coverage to 74 million people in the U.S. Delta Dental of California, Delta Dental of New York, Inc., Delta Dental of Pennsylvania and Delta Dental Insurance Company, together with our affiliate companies, form one of the nation's largest dental benefits delivery systems, covering 33 million enrollees. All of our companies are members, or affiliates of members, of the Delta Dental Plans Association, a network of 39 Delta Dental companies throughout the country.
Delta Dental is an equal opportunity employer. We are committed to building and maintaining a diverse and inclusive workplace for all employees. Applicants will not be discriminated against because of race, color, religion, creed, national origin, ancestry, citizenship status, sex (including pregnancy), sexual orientation, gender or identity expression, age, disability, marital status, medical status, veteran status or any other status protected under federal, state, or local law. In addition to federal law requirements, Delta Dental complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
Unfortunately, our Delta Dental Enterprise is unable to hire individuals residing in Alaska, North Dakota, Nebraska, Hawaii, Oklahoma, Vermont, Maine, West Virginia, New Hampshire, Wyoming, Puerto Rico or other US Territories at this time.
Proof of eligibility to work in the United States must be provided if selected for hire.
- Delta Dental includes: Delta Dental of California, Delta Dental Insurance Company, Delta Dental of Pennsylvania, and Delta Dental of New York
