Lead Clinical Reviewer

Delta-Dental; Sherwood (AR); On-site; USD 75,000 - 105,000; Full time

Job summary

Delta-Dental in Arkansas is seeking a Lead Clinical Reviewer to act as senior clinical review resource, directing first-level evaluations and coordinating daily workflow for the clinical review team.

The role emphasizes HIPAA compliance, mentoring reviewers, and escalating complex cases to the Dental Director while upholding established policies and processing requirements.

Qualifications

• Active Registered Dental Hygienist license in good standing.
• Five years of related clinical dental experience, including practice as a dental hygienist.
• Knowledge of ADA CDT coding, dental terminology, procedures, radiographic interpretation, and documentation requirements.
• Strong leadership, coaching, organization, and communication skills.
• Ability to prioritize work, meet deadlines, and work with minimal supervision.
• Proficiency with Microsoft Office and ability to learn claims-processing systems.

Responsibilities

• Review claims and pre-treatment estimates for first-level clinical evaluation and approve those meeting requirements.
• Refer claims that cannot be approved to a Dental Consultant; the Lead does not deny claims.
• Evaluate radiographs, treatment records, and documentation using clinical knowledge and guidelines.
• Coordinate daily workflow, assignments, coverage, priorities, and turnaround for the clinical review team.
• Serve as the first escalation point for Clinical Reviewers and escalate concerns to leadership.
• Lead calibration activities to promote consistent application of guidelines and policies.
• Conduct quality reviews and identify variations; recommend actions.
• Train, coach, and mentor Clinical Reviewers; support onboarding and development.
• Identify unusual practice patterns and potential issues; refer through escalation channels.
• Track trends in quality, productivity, turnaround, and training needs.
• Recommend updates to policies, tools, and workflows.
• Represent DDAR professionally with providers and maintain relationships.
• Comply with HIPAA and all regulatory requirements.

Skills

Clinical judgment

Leadership

Communication

Problem solving

Team building

Prioritization

Customer service

Education

Registered Dental Hygienist license

Tools

Microsoft Office

Job description

The Lead Clinical Reviewer serves as the senior clinical review resource and working lead for first-level clinical review operations. This position performs clinical review, approves claims within established authority, coordinates daily workflow, leads calibration and quality activities, and supports the development of Clinical Reviewers. The Lead Clinical Reviewer may approve a claim when established clinical, contractual, and processing requirements are met, but may not deny a claim. Claims that may result in an adverse benefit determination or require complex clinical judgment, policy interpretation, or exception handling are referred to a Dental Consultant or other designated authority for final determination.

Essential Duties and Responsibilities

• Review 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 Lead Clinical Reviewer does not deny claims.
• Evaluate radiographs, charting, narratives, treatment records, claim history, provider fees, and other supporting documentation using clinical knowledge, professional judgment, precedent, processing policies, and evidence-based guidelines.
• Coordinate daily workflow, work assignments, coverage, priorities, and turnaround expectations for the clinical review team while maintaining an active review workload.
• Serve as the first operational escalation point for Clinical Reviewers and elevate significant clinical, policy, compliance, provider, or workflow concerns to the Dental Director or Director of Utilization Management.
• Lead and facilitate routine calibration activities among Clinical Reviewers and Dental Consultants to promote consistent application of clinical guidelines, processing policies, documentation standards, and referral criteria.
• Conduct or coordinate quality reviews of the team, monitor approval and referral patterns, identify variation, and recommend training, clarification, corrective action, or process changes as appropriate.
• Train, coach, and mentor Clinical Reviewers; support onboarding, competency development, and ongoing education.
• Identify unusual practice patterns, utilization trends, potential fraud, waste, or abuse concerns, and other emerging issues and refer them through established escalation channels.
• Track and communicate trends related to quality, productivity, turnaround time, referral volume, documentation, and training needs.
• Recommend updates to clinical review policies, procedures, decision-support tools, training materials, and workflows.
• Serve as a subject matter resource to internal departments regarding dental terminology, procedures, CDT coding, documentation, and clinical review requirements.
• Represent DDAR 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 emerging workload, staffing, training, or turnaround risks promptly, before service levels are materially affected whenever reasonably possible.
• Provide initial guidance or a recommended next step for reviewer escalations within one business day when the matter is within the role’s authority.

Minimum Qualifications

• Active Registered Dental Hygienist license in good standing.
• Five years of related clinical dental experience, including experience as a practicing dental hygienist.
• Knowledge of ADA CDT coding, dental terminology, dental procedures, radiographic interpretation, and clinical documentation requirements.
• Demonstrated ability to apply professional judgment, analyze incomplete or complex information, and escape matters appropriately.
• Strong team-building skills and adept at building trust and cohesion across diverse teams.
• Strong leadership, coaching, organization, communication, customer service, and problem-solving skills.
• Ability to prioritize work, meet deadlines, and work with minimal supervision.
• Proficiency with Microsoft Office and the ability to learn claims-processing and related systems.

Preferred Qualifications

• Prior dental claims review, utilization management, clinical review, quality assurance, or dental insurance experience.
• Experience leading workflow, training team members, facilitating calibration, or performing quality reviews.