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.