10 Mar 2020

Full-Time Clinical Review Specialist

RecruitDQ – Posted by RecruitDQ Milwaukee, Wisconsin, United States

Job Description

The Clinical Review Specialist I provides timely and accurate review and authorization of dental services based on eligibility and contract requirements.


  • Successful completion of the Clinical Review Specialist training program
  • Read, interpret and analyze x-rays, models and requests for major dental services based on medical necessity, client coverage, provider participation and member eligibility, in accordance with contract language
  • Resolve claim and prior authorization suspends that require UM Review
  • Consistently meet productivity requirements
  • Maintain audit score of 95% or greater
  • Pass the IRR quarterly
  • Communicate and work effectively with co-workers and Leads to coordinate workload to ensure all work is completed daily
  • Knowledge of reference materials and documentation that contain market nuances
  • Respond to follow-ups Provide customer service via the telephone to providers regarding clinical issues
  • Other duties as assigned Represent DentaQuest in a professional manner at all times
  • Adhere to DentaQuest business processes Performs peer clinical reviews


  • High School Diploma or equivalent 1 year dental assisting experience
  • Ability to read and interpret x-rays, dental models, photos, and/or patient charts
  • Good interpersonal skills
  • Ability to work independently
  • Excellent oral and written communication skills
  • Efficient PC skills (Word, Excel, Outlook) Ability to prioritize and organize multiple tasks
  • Ability to remain organized with multiple interruptions Knowledge of telephone systems
  • Ability to work in excess of 40 hours in a week
  • Required to attend additional training as required/deemed necessary


  • Previous dental insurance experience a plus


  • Incumbent must be able to communicate effectively.
  • Requires overall light physical effort (up to 25lbs.)
  • Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer).
  • Ability to travel or move about within and outside serviced facilities required.
  • Incumbent works primarily in either a private or shared office environment.

How to Apply

To be considered for this role, please apply here: http://gr.8job.co/8IAWSIVS

Job Categories: Equal Opportunities. Job Types: Full-Time.

Job expires in 65 days.

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