Clinical Review and Education Representative

Clinical Review and Education Representative

Job Category: Clinical Review

Requisition Number: CLINI
001495

Location: Spokane, WA 99202, USA

Are you ready to put your dental expertise to work by reviewing claims and supporting clinical teams in delivering accurate and timely benefits decisions? As a Clinical Review and Education Representative, you will review and adjudicate dental claims by evaluating clinical documentation and records such as radiographs, narratives, and chart notes in accordance with group contracts and Delta Dental guidelines, ensuring accuracy, identifying potential fraud or abuse, and collaborating with Dental Consultants, Customer Service, and other internal teams to achieve one call resolution for providers and members.

The pay range for this position in Western Washington varies between $46,575 and $62,963, and for Eastern Washington between $45,083 and $60,946. Washington Dental Service and its affiliates intend to offer the selected candidate a base pay within this range, dependent on job‑related, non‑discriminatory factors such as experience, with adjustments for geographic location.

• Research and review dental claims and supporting clinical documentation and records, including radiographs, periodontal charts, intra‑ and extra‑oral images, narratives, and chart notes, to determine benefits based on group contracts and Delta Dental guidelines.
• Preview claims and appeals for completeness and accuracy before referring to Dental Consultants for a clinical determination.
• Review appeals for claims and predeterminations previously denied due to missing information, history violations, or claims processing errors.
• Participate in regular calibration sessions to ensure consistent application of claim review guidelines.
• Identify, document, and report suspected fraud, abuse, or unusual practice patterns during claim review.
• Respond to escalated provider calls from Support Team Representatives and answer clinical questions from Customer Service Representatives to support one‑call resolution.
• Represent the department on cross‑functional teams and committees as assigned.

• Demonstrated experience as a dental assistant or dental hygienist in a clinical or administrative setting.
• Proficient knowledge of dental terminology, dental anatomy, dental radiography, and interpretation of periodontal charts.
• Skilled in navigating and using technical systems and dental claims processing platforms.
• Ability to accurately review, document, and organize high volumes of claim information with strong attention to detail.
• Proficient in written and verbal communication for explaining clinical information to internal teams and external providers and office staff.
• Experience collaborating with cross‑functional teams in health care or dental operations.
• Working knowledge of claims adjudication workflows and appeals handling procedures.

Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and Tri Forza, are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

We are committed to the highest standards of information security and HIPAA compliance, ensuring the confidentiality, integrity, and protection of all data. All staff are expected to support this commitment by following relevant policies.