Clinical Reviewer

Clinical Reviewer

The Clinical Reviewer performs first-level clinical review of claims and pre-treatment estimates using established Delta Dental of Arkansas policies, clinical guidelines, contractual requirements, documentation standards, and delegated authority. The Clinical Reviewer may approve a claim when established requirements are met, but may not deny a claim. Claims that cannot be approved or that may result in an adverse benefit determination are referred to a Dental Consultant or other designated authority for final determination. The role also supports provider communication, accurate and timely workflow, issue identification, and continuous improvement.

Essential Duties and Responsibilities

· Review assigned claims and pre-treatment estimates requiring first-level clinical evaluation and approve claims that meet established clinical, contractual, processing, and documentation requirements.

· Refer claims that cannot be approved, including claims that may result in denial or another adverse benefit determination, to a Dental Consultant or other designated authority. The Clinical Reviewer does not deny claims.

· Evaluate radiographs, charting, narratives, treatment records, claim history, provider fees, and other supporting documentation using clinical knowledge, experience, precedent, processing policies, and evidence-based guidelines.

· Determine when additional documentation or higher-level clinical review is required and document review findings and processing instructions clearly in the claims system.

· Apply ADA CDT coding knowledge, dental terminology, clinical documentation standards, DDPA policies, DDAR procedures, and applicable contractual provisions consistently.

· Meet established quality, productivity, accuracy, and turnaround expectations and manage assigned work in accordance with team priorities.

· Participate in calibration meetings, training, quality reviews, and continuing education and apply resulting guidance consistently.

· Identify and escalate unusual practice patterns, utilization trends, potential fraud, waste, or abuse concerns, documentation issues, policy gaps, or recurrent processing problems through established channels.

· Serve as a resource to internal staff regarding dental terminology, procedures, coding, documentation, and clinical review requirements within the scope of the role.

· Collaborate with the Lead Clinical Reviewer, Dental Consultants, Claims, Professional Relations, and other departments to support accurate and efficient claim processing.

· Represent Delta Dental of Arkansas professionally in communications with participating providers and support constructive provider relationships.

· Comply with HIPAA, confidentiality, organizational policies, and all applicable legal and regulatory requirements.

· Perform other related duties as assigned.

Proactivity and Timeliness Expectations

· Communicate critical issues requiring immediate attention as soon as practicable and no later than the same business day.

· Escalate material quality, compliance, provider, operational, or workflow concerns within one business day of identification.

· Raise barriers that may affect assigned turnaround or accuracy promptly and before deadlines are missed whenever reasonably possible.

· When reporting a problem, provide relevant facts and a recommended next step when feasible.

Minimum Qualifications

· Five years of related experience in a clinical dental office, dental claims, clinical review, utilization management, or a comparable dental environment. A suitable combination of education, training, certification, and experience may be considered.

· Working knowledge of ADA CDT coding, dental terminology, dental procedures, and common clinical documentation.

· Ability to review and interpret radiographs, charting, narratives, treatment records, and claim history at the level required for assigned responsibilities.

· Strong analytical, organizational, communication, customer service, and problem-solving skills.

· Collaborative mindset with the ability to contribute effectively in a team setting.

· Ability to prioritize work, meet deadlines, exercise sound judgment, and work with minimal supervision.

· Proficiency with Microsoft Office and the ability to learn claims-processing and related systems.

Preferred Qualifications

· Active Registered Dental Hygienist license in good standing.

· Dental assisting or other relevant clinical dental credential.

· Prior dental claims review, utilization management, clinical review, or dental insurance experience.