Clinical Review Specialist

The Clinical Review Specialist is a hybrid position requiring one day a week in our Centennial, Colorado office.

Salary range: $30.82 - $36.45 per hour based upon years of experience, 40 hours per week plus benefits.

Closing date: Monday, April 8, 2024

Education and Qualifications: 

• Minimum of five (5) years of clinical experience as a registered dental hygienist in the state of Colorado required.
• Current/Active Registered Dental Hygiene License in the State of Colorado required.

Skills and Abilities: 

• Ability to analyze claims and research history to accurately process claims that require higher-level review, including an understanding of dental procedures and ADA CDT.
• Ability to interpret dental charting, progress notes, radiographs, and narratives submitted by dentists/offices to support claims and procedures.
• Knowledge of dental insurance industry regulations, statutes, and procedures.
• Understand the dental review process, importance of applying accurate and consistent processing procedures, attention to detail, and acknowledge the affect these processes have on all aspects of operations within Delta Dental of Colorado.
• Leverage self-motivation and initiative to resolves issues independently, often with limited information, and take responsibility for the results.
• Demonstrate excellent professional and clinical communication skills, both written and oral, including the ability to communicate ideas within the team, respect differences, and fully support the customer.
• Demonstrate strong computer knowledge, skills, and accuracy.

Essential Functions:

• Reviews/finalizes claims and pre-treatment estimates daily, making claim benefit determinations based on clinical necessity, group contracts and Delta Dental processing policies. Determine which claims require higher-level dental consultant review. Trouble shoot claims that have errors or issues that are not defined in the processing policy.
• Ability to make decisions for assignment of benefits based on processing policies and contract language, often making undefined decisions based on professional judgement.
• Adhere to processing policies and guidelines to ensure accurate claims processing and referrals to the dental consultant. Collaborate with the dental consultant on claims and code issues for decision-making.
• Researches pre-treatment estimates/claims for appropriate supporting documentation. Send requests to and place outreach phone calls to dental offices to receive additional information to ensure timely processing of claims.
• Monitor daily workflow and create achievable processing goals to ensure the quality and quantity of claims filed meet production needs and turnaround time.
• Collaboration with claims department, claims management, and other departments as needed.
• Identify issues with claims processing and elevate to Clinical Review Specialist Lead and Manager Claims.
• Working knowledge of benefit coverage, processing policy guidelines, procedures, and services provided by Delta Dental.
• Responsible for maintaining and ensuring all procedures in the department complies with HIPAA Standards and Regulations.

Working Conditions: 

• This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, and photocopiers. 
• Ability to perform the essential functions of the job with or without reasonable accommodation. 
• No physical effort beyond that is typically required in a normal office environment. 
• Requires flexible time schedule. The potential for tight deadlines or time periods of high workload might require additional hours. 
• Regular exposure to a computer screen. 
• This position is a hybrid role that requires one day a week in the office.   

Please note: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice. 

Delta Dental of Colorado offers a comprehensive compensation and benefits package. Some of the highlights from our benefits package include:

• Generous PTO
• 11 paid holidays
• 6 paid illness days
• Three affordable medical health plans
• Fantastic dental insurance plan
• Vision and hearing plan
• 401(k) match with immediate vesting
• Supplemental retirement savings plan
• Company-paid life insurance, short-term disability, and long-term disability policies
• Wellness program
• Tuition reimbursement
• ECO Passes for team members (we are near a light rail station!)
• Paid volunteer time off

Salary range: $30.82 - $36.45 per hour, 40 hours per week plus benefits.

Closing date: Monday, April 8, 2024

Delta Dental of Colorado is proud to be an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity, genetic information, military or veteran status, national origin, race, religion, sex, sexual orientation, or any other applicable status protected by state or local law.

Salary : $31 - $36