First-Level Dental Claims Clinician

Delta-Dental; Sherwood (AR); On-site; USD 55,000 - 75,000; Full time

Job summary

Delta Dental of Arkansas is seeking a Clinical Reviewer to perform first-level clinical review of claims and pre-treatment estimates. You will approve those meeting established requirements and refer others for final determination.

The role supports provider communication and efficient workflow while upholding confidentiality and regulatory standards. The ideal candidate has extensive experience in dental claims and strong knowledge of CDT coding, dental terminology, and clinical documentation.

Qualifications

• Five years of related experience in a clinical dental office, dental claims, clinical review, utilization management, or a comparable dental environment.
• 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.

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 elevate 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.

Skills

CDT coding

Dental terminology

Radiograph interpretation

Analytical thinking

Communication

Team collaboration

Organization

MS Office

Education

Active RDH license

Dental assisting credential

Job description

Delta Dental of Arkansas is seeking a Clinical Reviewer to perform first-level clinical review of claims and pre-treatment estimates. You will approve those meeting established requirements and refer others for final determination.

The role supports provider communication and efficient workflow while upholding confidentiality and regulatory standards. The ideal candidate has extensive experience in dental claims and strong knowledge of CDT coding, dental terminology, and clinical documentation.