Clinical Reviewer, Dental Hygienist

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct initial clinical evaluations of dental claims and pre-treatment estimates following established clinical guidelines, policies, and delegated authority.

• Approve claims that fulfill clinical, contractual, and documentation criteria.

• Assess radiographs, dental charting, narratives, treatment records, and claim histories utilizing evidence-based guidelines and clinical expertise.

• Refer intricate cases, potential denials, or adverse benefit determinations to Dental Advisors or designated clinical authorities for a conclusive decision.

• Identify necessary documentation, provide clear processing directives, and accurately document review findings in claims systems.

• Utilize knowledge of ADA CDT coding, dental terminology, clinical documentation standards, and contractual provisions.

• Recognize and escalate unusual practice patterns, utilization trends, potential fraud, waste, abuse concerns, policy gaps, or workflow challenges.

• Collaborate with Dental Advisors, Claims, Provider Relations, and team leads to enhance operations and provider communications.

• Ensure compliance with HIPAA, privacy standards, organizational policies, and regulatory requirements.

• Work on a five-day, eight-hour schedule totaling 40 hours per week, with shifts scheduled between 8:00 AM and 8:00 PM ET, including weekend and holiday rotation coverage.

⛳️ Requirements

• Over 5 years of clinical experience as a dental hygienist in a private practice or similar dental healthcare environment.

• Active Registered Dental Hygienist (RDH) license or equivalent clinical dental credential in good standing.

• Strong understanding of ADA CDT coding, dental terminology, dental procedures, and clinical documentation.

• Proven ability to read and interpret dental radiographs, charting, clinical narratives, and treatment records.

• Exceptional analytical, organizational, communication, and problem-solving abilities with a keen attention to detail.

• Proficient in claims-processing systems, electronic health/dental records, and standard digital tools.

• Experience with technology-driven workflow enhancements, especially with AI/LLM tools.

• Previous experience in dental insurance claims review, utilization management, or health plan clinical operations, preferably within a Medicare Advantage or managed care environment.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plan with low or no premium.

• Generous paid time off.

• $100 monthly mobile or internet stipend.

• Stock options available for all employees.

• Bonus eligibility for all positions excluding Director and above.

• Parental leave program.

• 401K program.