Dental Auditor

Dental Auditor

The Dental Auditor ensures clinical quality, regulatory compliance, and accurate claims processing across dental plans and provider networks. This role conducts audits and reviews, identifies risks and trends, and partners with internal teams and providers to drive corrective actions and continuous improvement.

Key Responsibilities

• Perform clinical and administrative audits of dental records, claims, and utilization to assess compliance with policies, CADP standards, state/federal regulations, and payer requirements.
• Evaluate medical necessity, coding accuracy (CDT), documentation quality, and adherence to evidence-based guidelines.
• Prepare audit reports with findings, risk ratings, corrective action recommendations, and follow-up validation.
• Collaborate with QM, Provider Relations, Compliance, SIU/Anti-Fraud, and Operations to address issues, implement action plans, and monitor outcomes.
• Support readiness for external reviews and accreditation surveys; maintain audit tools, checklists, and SOPs.
• Analyze trends and KPIs (error rates, turnaround times, denial patterns) and present insights to leadership.
• Provide provider education and feedback to improve documentation, coding, and clinical quality.
• Maintain strict confidentiality and data security in accordance with HIPAA and company policies.

Required Qualifications

• Licensed Dentist in California with an active
• CADP-certified auditor (preferred). If not currently certified, must obtain certification promptly upon hire.
• Strong knowledge of dental benefit design, claims workflows, CDT coding, utilization management, and quality improvement principles.
• Excellent analytical, documentation, and report-writing skills; proficiency with audit software and MS Office/Google Workspace.
• Strong communication skills with the ability to deliver clear feedback to providers and cross-functional partners.

Preferred Qualifications

• Minimum 2 years of experience working with dental plans (payer, DSO, or managed care setting).
• Experience with CADP standards, NCQA-like quality frameworks, or similar accreditation/compliance environments.
• Familiarity with fraud/waste/abuse detection, root cause analysis, and corrective action planning.
• Experience training or educating providers on documentation and coding best practices.

Work Schedule and Environment

• Full-time, Monday–Friday, with occasional flexibility for special audits or reviews.
• Primarily office-based, with potential travel for provider site audits within California.

Performance Metrics

• Accuracy and completeness of audit findings and reports.
• Timeliness of audits and follow-up validations.
• Reduction in error rates and repeat findings.
• Provider satisfaction with education and feedback.
• Compliance with CADP and regulatory standards.

Equal Opportunity Statement We are an equal opportunity employer and value diversity. All employment decisions are based on qualifications, merit, and business need.