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Dental Hygienist
NationsBenefits, LLC
Florida, USA
Full-time
Junior · 2+ years experience
Onsite
Discovered 2 days ago
Role Overview
The Dental Hygienist provides clinical expertise to support claims processing and member and provider services for approximately 400,000 members effective January 1, 2027.
The role performs first-level clinical screening of claims, x-rays, periodontal charting and narratives, and prepares clinical summaries.
Utilization review recommendations and adverse determinations are made by Fluent clinical dental directors; the hygienist ensures cases are complete, well documented, and correctly routed.
Full Job Posting
Key Responsibilities
- Review claims and attachments (radiographs, perio charting, narratives, intraoral photos) for completeness and consistency with plan clinical policies.
- Triage claims referred by Claims Processors, resolve clinical questions within scope, and escalate cases requiring dental director review to Fluent with a concise clinical summary.
- Coordinate with Fluent on referrals, turnaround, and outcomes; track pending cases and ensure recommendations are applied correctly.
- Support appeals and grievances by preparing clinical case summaries and documentation.
- Serve as clinical resource to Claims, Customer Service, and Provider Support on CDT codes, treatment sequencing, periodontal and preventive services, and benefit application.
- Train and coach processors on clinical topics such as perio staging, radiographic documentation, and code selection.
- Help develop and maintain clinical coverage criteria, claim edits, and reference materials with Fluent and leadership.
- Contribute to quality audits and identify provider billing patterns for referral to compliance or SIU.
- Maintain confidentiality of PHI and comply with HIPAA and applicable state regulations.
Qualifications
- Graduate of an accredited dental hygiene program; active, unrestricted RDH license in good standing in the United States (state requirement to be confirmed).
- 2+ years of clinical practice experience required; dental insurance, claims review, or utilization review experience strongly preferred.
- Strong knowledge of CDT codes, periodontal classification, radiographic interpretation, and dental benefit concepts.
- Excellent written and verbal communication, analytical skills, and sound judgment.
- Proficient with Microsoft Office and claims or case management systems.
- Preferred
- Experience in a payer or third-party administrator environment.
- Experience with Medicare Advantage or Medicaid dental programs.
- Bachelor degree in dental hygiene or health-related field.
- Bilingual (English/Spanish).
- Performance Measures
- Clinical referral turnaround time and completeness
- Accuracy and consistency of clinical screening versus dental director outcomes
- Appeal summary quality and timeliness
- Feedback from Claims and Customer Service partners
- Compliance and documentation quality
- Working Conditions
- Primarily sedentary computer-based work. Standard business hours with flexibility during launch and peak period
Preferred Qualifications
- 2+ years of clinical practice experience required; dental insurance, claims review, or utilization review experience strongly preferred.
- Preferred
About NationsBenefits, LLC
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