Professional Review Specialist 

Duties and responsibilities

Professional Review

• Screen dental claims for proper treatment descriptions/dental codes and proper submission of diagnostic materials in order to determine contractual obligation to treatment plan submitted.

• Determine when claims require further review and benefit determination by the dental consultants. Work with dental consultants to reach a final decision.

• Provide assistance over the phone to dental offices and patients with questions regarding claim adjudication.

• Maintain strict confidentiality of member-protected health information.

Data Entry/Record Keeping

Meticulously document all steps in the process and resulting decisions, including those from the dental consultants, for the proper benefit determination and adjudication of the claim.

Other duties as assigned

Experience and qualifications

• Dental Hygiene license and experience preferred.

• A minimum of 3 years work experience related to dental offices required.

• Strong knowledge of dental terminology.

• Strong self-motivation and ability to work independently.

• Excellent oral and written communication skills and the ability to interact with internal and external stakeholders in an effective and positive manner.