Clinical Research and Escalation Specialist

Join our team at NCD, a top-tier insurance provider, consisting of a unique and eclectic group of winners, nerds, and gamers who balance a fun, kind, and thoughtful approach to life with an unwavering commitment to unparalleled member satisfaction. Our ecosystem is rooted in our five core values: Relentless Positivity, Growth Obsessed, Get it Done, Helpful Spirit, and Solution Driven. We are not just coworkers, but a community, working tirelessly towards 'Spreading the Smile' to our members, agents, and each other. NCD is at the forefront of dental and vision insurance, in partnership with our carrier partners MetLife, VSP, and Zurich. Our continuous growth is a testament to our commitment to delivering outstanding agent and customer satisfaction. If you are ready to win each day, are eager to grow, and aspire to contribute to an organization that is setting the pace in the industry, then we are looking for you. Together, let’s drive change and take NCD to new heights. Join us and become a vital part of our success story as we continue to transform lives and 'Spread the Smile. Summary This position is responsible for researching and providing resolutions for negative online reviews, escalated claims issues, and formal member complaints in a timely and effective manner. This includes reviewing the clinical details of escalated dental and vision claims — procedure coding, clinical documentation, and carrier clinical/consultant review determinations — to confirm whether outcomes were applied correctly and to explain them clearly to members. The successful candidate will have excellent research, problem-solving, and communication skills, along with a working knowledge of dental/clinical claim concepts, to help maintain and improve our company's reputation and customer satisfaction. This position is 100% remote. Essential Duties and Responsibilities Monitor and review customer feedback, complaints, and negative reviews across various online platforms, including social media, review websites, and customer support channels. Research and analyze complex issues related to customer complaints and escalated claims, identifying patterns, root causes, and potential resolutions. Review the clinical details of escalated and denied dental and vision claims — including CDT procedure codes, tooth- and quadrant-level detail, clinical narratives, radiographs, and Explanations of Benefits (EOBs) — to determine whether claim outcomes were applied correctly (e.g., covered vs. non-covered procedures, frequency and age limitations, waiting periods, and missing-tooth provisions). Interpret carrier clinical and consultant claim-review determinations (e.g., MetLife, Zurich) and translate clinical denial rationale into clear, empathetic, plain-language explanations for members. Coordinate with carrier clinical reviewers, dental consultants, and provider offices to obtain the clinical records, radiographs, narratives, and pre-authorization documentation needed to research and resolve disputes. Evaluate coordination of benefits (COB) at the procedure level, and identify clinical denial patterns that may indicate systemic issues or regulatory (DOI) complaint risk. Collaborate with cross-functional teams, including MC Training, Engineering, and Sales and Marketing, to gather necessary information and develop comprehensive solutions for member issues. Resolve escalated member issues in a timely and professional manner, ensuring customer satisfaction and maintaining a positive company brand and image. Communicate with customers through various channels, including email, phone, text, and online review platforms to address concerns, provide updates, and resolve issues. Document all interactions, findings, and resolutions in our customer relationship management (CRM) system, maintaining accurate and up-to-date records. Support fraud, waste, and abuse review through clinical claim and provider-signal analysis, including case documentation and referral preparation. Identify opportunities for process improvements and recommend changes to enhance the overall member experience. Assist in the development and maintenance of standard operating procedures (SOPs) and best practices for the department. Participate in ongoing training and development opportunities to stay current on industry trends, best practices, and company policies. Perform additional tasks and duties as assigned by the management team. Qualifications Bachelor's degree in business, communications, or a related field, or equivalent work experience. Minimum of 3 years of experience in customer service, with a focus on research, problem-solving, and issue resolution; dental, vision, or health insurance claims experience preferred. Working knowledge of dental terminology and CDT dental procedure coding, and familiarity with clinical claim-adjudication concepts such as dental necessity, frequency and age limitations, waiting periods, and missing-tooth provisions. Experience reviewing clinical documentation, dental records, radiographs, or EOBs — for example, in a dental front/back office, dental billing and coding, or dental/health insurance claims role. Ability to interpret clinical denial rationale and explain it to members in clear, non-technical language. Dental coding or clinical certification a plus (e.g., Certified Dental Coder (CDC), RDA/CDA, or a claims/coding certification). Strong analytical and research skills, with the ability to identify patterns and root causes of complex issues. Excellent verbal and written communication skills, with a focus on empathy, professionalism, and active listening. Demonstrated ability to work collaboratively with cross-functional teams and build positive relationships. Proficiency in product knowledge and using CRM systems and standard office software, including Microsoft Office Suite and Google Workspace. Strong organizational and time management skills, with the ability to prioritize tasks and manage multiple projects simultaneously. Demonstrated commitment to providing exceptional customer service and maintaining a positive company reputation. Company-paid health, dental, life, and disability insurance 401(k) with employer match Opportunity for professional development Work from home allowance and support Positive work environment NCD is an Equal Opportunity Employer. We are committed to building a team that reflects a variety of backgrounds, perspectives, and skills. We believe our differences make us stronger and help us better serve our members, agents, partners, and each other. #J-18808-Ljbffr NCD