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Professional Review Clinical Specialist

Delta Dental Of Virginia
Full-time
On-site
Roanoke, Virginia, United States

Position Summary

Seeking Dental Hygienist to review claims with the submitted diagnostic material to make proper benefit determinations based on group contracts and DeltaUSA and departmental established guidelines/policies. Responsible for clearing up queues on a daily basis and to pend appropriate claims for additional information. Refers claims to dental consultants for review.  

Location

Candidates located more than 1 hour outside of our corporate office in Roanoke, VA and residing in the following states may be considered for remote work: FL, GA, ID, MD, NC, NE, SC, TN, VA, WI, WV

Essential Functions

  • Reviews diagnostic material (i.e. x-rays, periodontal charting, etc.) to determine appropriate benefits.
  • Adjudicate claim benefit review requests in a timely manner.
  • Refers claims to dental consultant for review when diagnostic materials do not appear to support the procedure requested.
  • Follows DeltaUSA guidelines and departmental guidelines/policies for claims processing.
  • Works in team concept with the CCU and other departments within Delta Dental.
  • Maintain accuracy and production numbers to meet department expectations.
  • Audited to ensure KPI’s are met monthly.

Qualifications/Education/Experience

  • Registered Dental Hygienist (RDH) or Dental office manager/dental insurance experience required. 
  • Knowledge interpreting dental x-rays.
  • The ability to follow established procedures with moderate decision-making.
  • Extensive computer knowledge/skills.
  • Strong interpersonal and communication skills.
  • The ability to focus for long periods of time.
  • A positive attitude with ability to adapt to change and learn new things.

Physical Demands and Work Environment:  

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

  • Physical demands: While performing the duties of this job, the employee is occasionally required to walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; balance; stoop; talk or hear. Use of hands is required for such technological devices such as a computer, telephone  and others. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus. The employee will be required to travel (sometimes long distances) to attend required meetings.
  • Work environment: The work is limited to the office environment with occasional trips to other office facilities or locations necessitating walking outdoors or driving. The noise level in the work environment is usually minimal.