Clinical Review and Education Representative

Essential Responsibilities

• Research and review dental claims and supporting clinical documentation and records including radiographs, periodontal charts, intra and extra oral images, narratives, and chart notes to determine benefits based on group contracts and Delta Dental guidelines.
• Preview claims and appeals for completeness and accuracy before referring to Dental Consultants for a clinical determination.
• Review appeals for claims and predeterminations previously denied due to missing information, history violations, or claims processing errors.
• Participate in regular calibration sessions to ensure consistent application of claim review guidelines.
• Identify, document, and report suspected fraud, abuse, or unusual practice patterns during claim review.
• Respond to escalated provider calls from Support Team Representatives and answer clinical questions from Customer Service Representatives to support one call resolution.
• Represent the department on cross functional teams and committees as assigned.

Experience, Skills, and Education

• Demonstrated experience as a dental assistant or dental hygienist in a clinical or administrative setting.
• Proficient knowledge of dental terminology, dental anatomy, dental radiography, and interpretation of periodontal charts.
• Skilled in navigating and using technical systems and dental claims processing platforms.
• Accurate in reviewing, documenting, and organizing high volumes of claim information with strong attention to detail.
• Proficient in written and verbal communication for explaining clinical information to internal teams and external providers and office staff.
• Experience collaborating with cross-functional teams in healthcare or dental operations.
• Working knowledge of claims adjudication workflows and appeals handling procedures.

Pay Range: For Western Washington, the pay range is $46,575 – $62,963, and for Eastern Washington, it is $45,083 - $60,946. Base pay will be determined based on experience and geographic location.

Benefits: Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza offers a highly competitive medical, dental, and vision plans, a generous 401k match, and all employees accrue vacation and sick time from their first day. Additional benefits include tuition reimbursement, professional development plans, and employee-led communities.

Company Values: We are Accountable. We lean in with Courage. We stay Curious. We are Inclusive. We act with Integrity.

Equal Opportunity Employer: Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza are committed to equal opportunity employment and do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.