Dental Consultant - Clinical Review

The Clinical Review Dental Consultant utilizes clinical expertise of dental procedures and practices to adjudicate prior authorization requests and claims. Active Texas Dental License (required) • Process and/or adjudicate claims or treatment authorization requests that require professional review; review supporting documentation and adjudicate by applying dental standards. • Identify when additional information is necessary to make a claim or prior authorization determination and collaborate with internal and external parties to gather information where appropriate. • Respond to inquiries from internal and/or external stakeholders regarding claim or prior authorization requests. • Utilize best practices in identification of potential Fraud, Waste, and Abuse (FWA) issues and report any identified issues to the appropriate party for resolution. • Process requests for re-evaluation. • May review and analyze documentation related to patient quality-of-care complaints, state hearings, first level appeals, audits, Conlan cases, and maintain logs of resolved grievances as needed. • Conduct or assist in developing seminars or training programs as needed. • 2+ w/Bachelor’s degree • A DDS or DMD degree from an accredited dental school; A minimum of 5 years of private dentistry practice experience and an active, unencumbered dental license with the Dental Board required. • Strong organizational skills that reflect ability to perform and prioritize multiple tasks seamlessly with excellent attention to detail • Excellent analytical and problem solving skills • Excellent interpersonal, verbal, and written communication skills • Proficiency with the Microsoft Office Suite, including Word, Excel, Outlook, etc. • Ability to adapt quickly in a fast-paced environment • Knowledge of Current Dental Terminology (CDT) codes, dental nomenclature, and industry trends • Knowledge of Delta Dental products, policies, claims, eligibility and underwriting guidelines Required Licenses Active Texas Dental License DDS - Doctor Of Dental Surgery. DDM - Doctor Of Dental Medicine. Base Pay Information The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental’s assessment of the candidate’s knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity. Pay Grade 22. $92,500 - $200,400 Behind the smile! We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. Our life-changing rewards package includes: • Competitive base and incentive pay • 401(k) with robust matching and non-matching contributions • Rich medical & pharmacy benefits • 100% employer-paid dental and vision benefits • Holistic wellbeing program with deep financial incentives • Generous paid time off plus 12 paid holidays and your birthday off • Culture of growth and learning: career development; tuition reimbursement; recognition program • Family support: adoption assistance, fertility treatment, child, elder & pet care assistance • Social responsibility and volunteer opportunities • Employee discount program Fair Chance Ordinances and Criminal Background Considerations This position requires that the applicant undergo a background check. Qualified applicants with arrest or conviction records will be considered for employment in accordance with any applicable federal, state or local laws, including, but not limited to, the California Fair Chance Act, the Los Angeles County Fair Chance Ordinance, the City of Los Angeles Fair Chance Initiative for Hiring Ordinance, the San Francisco Fair Chance Ordinance, and/or New York Corrections Law Article 23-A. Important Work Authorization Information Please note, Delta Dental will not sponsor applicants for work visas for this position. Apply tot his job