Job Details

Description

Are you ready to apply your clinical expertise to advance utilization management, guide benefit determinations, and contribute to excellence in dental claim review? As a valued member of our Clinical Review team, you will work collaboratively to evaluate clinical records and documentation from dental offices, make benefit determinations in alignment with contractual agreements and Delta Dental guidelines, and partner with technology and innovation teams to enhance claim review accuracy and efficiency in support of multiple Delta Dental member companies.

At Delta Dental of Washington our vision is that all people can enjoy good oral and overall health, with no one left behind. We succeed because of a shared commitment to a set of values that guide everything we do – for our customers, for our communities, and for each other. We are Accountable. We lean in with Courage. We stay Curious. We are Inclusive. We act with Integrity.

We offer a highly competitive medical, dental and vision plans as well offering a generous 401k match and all employees start accruing vacation and sick time from their very first day. We empower employee development through our tuition reimbursement plan, professional development plans, and employee-led communities.

The pay range for this position in Western Washington varies between $145,530.00 – $160,000.00, and for Eastern Washington varies between $122,215.00 - $140,468.00. Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza intends to offer the selected candidate a base pay within this range, dependent on job-related, non-discriminatory factors such as experience. Base pay will also be adjusted based on the candidate's geographic location.

Essential Responsibilities include the following: The list of responsibilities listed is not intended to be comprehensive. Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza reserve the right to change the responsibilities at any time with or without notice.

• Provide expert clinical interpretation and decision-making in accordance with contractual agreements, policies from multiple Delta Dental member companies, and industry guidelines for claims, re-evaluations, final reviews, network quality management cases, and subscriber appeals.
• Respond to verbal and written inquiries from internal and external stakeholders regarding clinical treatment, processing policies, and payment determinations
• Ensure consistency and accuracy in decision-making by adhering to all requirements of the Calibration Program
• Conduct on-site dental office audits when required to evaluate compliance, quality, and adherence to industry standards
• Actively participate in programs and workgroups including Utilization Management, Network Quality Management, Subscriber Appeals, and Waste, Abuse, Verification, and Education (WAVE) as needed
• Build and maintain professional relationships with the provider community through direct communication, engagement with dental societies, collaboration with dental schools, and participation in professional associations
• Collaborate with internal teams to enhance utilization management, fraud, waste, and abuse detection, and claim review processes by providing clinical expertise, and ensuring alignment with payer clinical policies and industry guidelines.

Experience, skills, and education do you need to have to succeed in the position: The requirements listed below are representative of the knowledge, skill, and/or ability required to successfully perform the essential functions of the position.

• Comprehensive knowledge of all dental disciplines’ terminology, anatomy, radiography, and clinical treatment planning
• Proven ability to interpret and apply payer clinical policies, contractual agreements, and industry guidelines to claim adjudication
• Experience with utilization management processes, including benefit determinations, medical necessity review, and policy compliance
• Exceptional written and verbal communication skills for explaining clinical decisions to internal staff and external stakeholders and providers
• Commitment to maintaining calibration and consistency in clinical decision-making
• Knowledge of fraud, waste, and abuse detection principles, including familiarity with statistical and pattern analysis in dental claims
• Strong analytical skills to review complex clinical documentation and make objective, evidence-based determinations
• Ability to collaborate effectively with cross-functional teams, including clinical review, provider relations, compliance, and technology teams
• D.S. or D.M.D. degree and at least five years of clinical experience as a licensed dentist after graduating from dental school
• Current license to practice dentistry in the state of Washington, maintained in good standing

Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

We are committed to the highest standards of information security and HIPAA compliance, ensuring the confidentiality, integrity, and protection of all data. All staff are expected to support this commitment by following relevant policies.

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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
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