Delta Dental Ins. hiring Clinical Review Specialist in Dallas, Texas, United States | LinkedIn (2024)

Job DescriptionPlease note that while listed as remote, we are focused on individuals located in the follow locations: Utah, Georgia, Florida, Texas.

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 Diploma
• 3+ years clinical dental experience and Associates degree or higher in Business Administration or related field preferred.
• Certificate or higher in Dental Assisting required.
• Ability to read, interpret and analyze x-rays required.
• CDA-Certified Dental Assistant. Preferred*
• 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 InformationBehind the smile! We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. Our life-changing rewards package includes:

• Competitive base and incentive pay
• 401(k) with robust matching and non-matching contributions
• Rich medical & pharmacy benefits
• 100% employer-paid dental and vision benefits
• Holistic wellbeing program with deep financial incentives
• Generous paid time off plus 12 paid holidays and your birthday off
• Culture of growth and learning: career development; tuition reimbursem*nt; recognition program
• Family support: adoption assistance, fertility treatment, child, elder & pet care assistance
• Social responsibility and volunteer opportunities
• Employee discount program

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

About The TeamAt Delta Dental, we're behind millions of smiles and counting. For over 68 years, we've served our communities by increasing access to affordable, quality care - but that commitment to care extends beyond the people we serve, to the dedicated employees who make those smiles genuine. We've come this far by building equitable programs that offer opportunities for advancement, create meaningful connections and improve the lives of our employees and their families. Because we know that when we take exceptional care of each other, we can make a positive impact for all.

We champion an inspirational workplace through our commitment to trust, service, excellence and innovation. Joining us means working for a company that offers stability and balance, opportunities for leadership at all levels, and a work environment focused on teamwork and camaraderie.

Discover the smiling faces behind Delta Dental and experience our values and culture in action by connecting with us on social media. Follow Delta Dental Ins. on Facebook and Instagram, on Facebook and Instagram, Delta Dental Ins. on Twitter and Delta Dental Ins. on LinkedIn. If you've got an appetite for innovation and want to be a part of a team that's transforming the future of health care, join us!

Since 1955, we have offered comprehensive, high-quality oral health care benefits to millions of enrollees and built the strongest network of dental providers in the country. The Delta Dental of California network includes affiliates Delta Dental Insurance Company; Delta Dental of Pennsylvania; Delta Dental of New York, Inc.; Delta Dental of the District of Columbia; Delta Dental of Delaware, Inc.; and Delta Dental of West Virginia, providing dental benefits to more than 31 million people across 15 states, the District of Columbia, Puerto Rico and the Virgin Islands.

The company and its affiliates are part of Delta Dental Plans Association (DDPA), a not-for-profit national association based in Oak Brook, Illinois. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories. We offer vision coverage through DeltaVision in 15 states and the District of Columbia. Collectively, we deliver benefits to more Americans than any other dental insurance company.

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, District of Columbia (Washington D.C.) 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

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