Lead Clinical Reviewer

Lead Clinical Reviewer

The Lead Clinical Reviewer serves as the senior clinical review resource and working lead for first-level clinical review operations. This position performs clinical review, approves claims within established authority, coordinates daily workflow, leads calibration and quality activities, and supports the development of Clinical Reviewers. The Lead Clinical Reviewer may approve a claim when established clinical, contractual, and processing requirements are met, but may not deny a claim. Claims that may result in an adverse benefit determination or require complex clinical judgment, policy interpretation, or exception handling are referred to a Dental Consultant or other designated authority for final determination.

Essential Duties and Responsibilities

• Review claims and pre-treatment estimates requiring first-level clinical evaluation and approve claims that meet established clinical, contractual, processing, and documentation requirements.

• Refer claims that cannot be approved, including claims that may result in denial or another adverse benefit determination, to a Dental Consultant or other designated authority. The Lead Clinical Reviewer does not deny claims.

• Evaluate radiographs, charting, narratives, treatment records, claim history, provider fees, and other supporting documentation using clinical knowledge, professional judgment, precedent, processing policies, and evidence-based guidelines.

• Coordinate daily workflow, work assignments, coverage, priorities, and turnaround expectations for the clinical review team while maintaining an active review workload.

• Serve as the first operational escalation point for Clinical Reviewers and elevate significant clinical, policy, compliance, provider, or workflow concerns to the Dental Director or Director of Utilization Management.

• Lead and facilitate routine calibration activities among Clinical Reviewers and Dental Consultants to promote consistent application of clinical guidelines, processing policies, documentation standards, and referral criteria.

• Conduct or coordinate quality reviews of the team, monitor approval and referral patterns, identify variation, and recommend training, clarification, corrective action, or process changes as appropriate.

• Train, coach, and mentor Clinical Reviewers; support onboarding, competency development, and ongoing education.

• Identify unusual practice patterns, utilization trends, potential fraud, waste, or abuse concerns, and other emerging issues and refer them through established escalation channels.

• Track and communicate trends related to quality, productivity, turnaround time, referral volume, documentation, and training needs.

• Recommend updates to clinical review policies, procedures, decision-support tools, training materials, and workflows.

• Serve as a subject matter resource to internal departments regarding dental terminology, procedures, CDT coding, documentation, and clinical review requirements.

• Represent DDAR professionally in communications with participating providers and support constructive provider relationships.

• Comply with HIPAA, confidentiality, organizational policies, and all applicable legal and regulatory requirements.

• Perform other related duties as assigned.

Proactivity and Timeliness Expectations

• Communicate critical issues requiring immediate attention as soon as practicable and no later than the same business day.

• Escalate material quality, compliance, provider, operational, or workflow concerns within one business day of identification.

• Raise emerging workload, staffing, training, or turnaround risks promptly, before service levels are materially affected whenever reasonably possible.

• Provide initial guidance or a recommended next step for reviewer escalations within one business day when the matter is within the role’s authority.

Minimum Qualifications·

Active Registered Dental Hygienist license in good standing.

• Five years of related clinical dental experience, including experience as a practicing dental hygienist.

• Knowledge of ADA CDT coding, dental terminology, dental procedures, radiographic interpretation, and clinical documentation requirements.

• Demonstrated ability to apply professional judgment, analyze incomplete or complex information, and escalate matters appropriately.

• Strong team-building skills and adept at building trust and cohesion across diverse teams.

• Strong leadership, coaching, organization, communication, customer service, and problem-solving skills.

• Ability to prioritize work, meet deadlines, and work with minimal supervision.

• Proficiency with Microsoft Office and the ability to learn claims-processing and related systems.

Preferred Qualifications

• Prior dental claims review, utilization management, clinical review, quality assurance, or dental insurance experience.

• Experience leading workflow, training team members, facilitating calibration, or performing quality reviews.