Job description
Description
Come join the Professional Services team at Delta Dental of Wisconsin. This position is located at our new corporate headquarters in Stevens Point. The Clinical Review Specialist is a paraprofessional responsible for tasks requiring clinical review expertise, including claim review, appeals and grievances, and fraud and abuse. Working directly with subscribers and dental office staff, this position also provides clinical review support to other internal departments.
Delta Dental of Wisconsin offers a comprehensive benefit package which includes health and dental insurance, employer match within our 401(k) retirement plan, and a generous Paid Time Off program. You do not want to miss this opportunity, apply today.
In this role Clinical Review Specialists will:
- Read, interpret, and analyze x-rays, progress notes, and other clinical documentation to determine benefit in accordance with contract language and coverage limits
- Evaluate provider utilization patterns and maintain provider/facility review suspend flags
- Acknowledge, resolve, track, and report member grievances in accordance with federal and state regulations
- Manage claims that require consulting dentist review
- Review and resolve claim appeals that require clinical review
- Recognize, investigate and resolve dentist contract non-compliance as it relates to dental claims
- Monitor DeltaUSA Processing Policy compliance; understand and communicate policies
- Cooperate with other Delta Dental member companies to achieve claim issue resolution
- Investigate and resolve fraud, waste, and abuse allegations
Qualifications
Education
Preferred
Experience
Required
Preferred
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)
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