Dental Claims Quality Reviewer

Delta Dental of Arkansas; Sherwood (AR); On-site; USD 60,000 - 80,000; Full time

Job summary

Delta Dental of Arkansas is seeking a Clinical Reviewer to perform first-level clinical evaluation of claims and pre-treatment estimates in line with policies, guidelines, and contractual requirements. The role supports provider communication, timely workflow, and documentation standards.

The Clinical Reviewer may approve when requirements are met and refers non-approvable cases to a Dental Consultant for final determination, with emphasis on accuracy and compliance.

Qualifications

• Five years of related experience in a clinical dental environment.
• Working knowledge of ADA CDT coding and dental terminology.
• Ability to interpret radiographs, charting, narratives, and treatment records.
• Strong analytical, organizational, and communication skills.
• Collaborative mindset and ability to work in a team.
• Ability to prioritize and meet deadlines with minimal supervision.
• Proficiency with Microsoft Office and learning claims-processing systems.

Responsibilities

• Review claims and pre-treatment estimates for first-level clinical evaluation and approve those meeting requirements.
• Refer non-approvable claims to Dental Consultant or designated authority.
• Evaluate radiographs, charting, narratives, and supporting documentation using clinical knowledge.
• Determine when additional documentation or higher-level review is needed.
• Apply ADA CDT coding, dental terminology, and company policies consistently.
• Meet quality, productivity, and turnaround expectations and manage workload.
• Participate in calibration, training, and quality reviews.
• Identify unusual patterns or potential fraud and escalate through proper channels.
• Serve as a resource on dental terminology, procedures, and coding.
• Collaborate with Lead Clinical Reviewer, Dental Consultants, and other departments to support claim processing.

Skills

ADA CDT coding knowledge

Clinical review

Analytical thinking

Communication

Team collaboration

Problem solving

Customer service

Microsoft Office

Education

Active RDH license

Dental credential

Tools

Microsoft Office

Job description

Delta Dental of Arkansas is seeking a Clinical Reviewer to perform first-level clinical evaluation of claims and pre-treatment estimates in line with policies, guidelines, and contractual requirements. The role supports provider communication, timely workflow, and documentation standards.

The Clinical Reviewer may approve when requirements are met and refers non-approvable cases to a Dental Consultant for final determination, with emphasis on accuracy and compliance.