The Staff Dental Consultant reviews dental claims and clinical information to determine medical necessity, benefit eligibility, and appropriateness of care. They also provide clinical expertise for appeals, grievances, and peer-to-peer reviews while supporting departmental compliance and quality reporting.
The specialist researches, analyzes, and resolves complex dental benefit cases, including compliance issues, appeals, and grievances for government programs. They also coordinate with legal and compliance teams to ensure timely resolution and accurate documentation of claims.
The specialist analyzes and adjudicates dental claims to identify potential fraud or aberrant treatment patterns. They also provide dental expertise and interpretations of policies to internal and external stakeholders.
The investigator is responsible for researching and reporting on questionable conduct by providers and members regarding claims, treatment patterns, and contract compliance. They will conduct audits, interview relevant parties, preserve evidence, and assist law enforcement or legal counsel in fraud detection and prosecution.
The Professional Services Representative is responsible for recruiting and retaining dentists within the Delta Dental network while logging all interactions in Salesforce. They also conduct presentations, resolve claims processing issues, and represent the company at various dental meetings and community functions.
