Clinical Research & Escalation Specialist

Summary

This position is responsible for researching and providing resolutions for negative online reviews, escalated claims issues, and formal member complaints in a timely and effective manner. This includes reviewing the clinical details of escalated dental and vision claims — procedure coding, clinical documentation, and carrier clinical/consultant review determinations — to confirm whether outcomes were applied correctly and to explain them clearly to members. The successful candidate will have excellent research, problem-solving, and communication skills, along with a working knowledge of dental/clinical claim concepts, to help maintain and improve our company's reputation and customer satisfaction.

Essential Duties and Responsibilities

• Monitor and review customer feedback, complaints, and negative reviews across various online platforms, including social media, review websites, and customer support channels.

• Research and analyze complex issues related to customer complaints and escalated claims, identifying patterns, root causes, and potential resolutions.

• Review the clinical details of escalated and denied dental and vision claims — including CDT procedure codes, tooth- and quadrant-level detail, clinical narratives, radiographs, and Explanations of Benefits (EOBs) — to determine whether claim outcomes were applied correctly (e.g., covered vs. non-covered procedures, frequency and age limitations, waiting periods, and missing-tooth provisions).

• Interpret carrier clinical and consultant claim-review determinations (e.g., MetLife, Zurich) and translate clinical denial rationale into clear, empathetic, plain-language explanations for members.

• Coordinate with carrier clinical reviewers, dental consultants, and provider offices to obtain the clinical records, radiographs, narratives, and pre-authorization documentation needed to research and resolve disputes.

• Evaluate coordination of benefits (COB) at the procedure level, and identify clinical denial patterns that may indicate systemic issues or regulatory (DOI) complaint risk.

• Collaborate with cross-functional teams, including MC Training, Engineering, and Sales and Marketing, to gather necessary information and develop comprehensive solutions for member issues.

• Resolve escalated member issues in a timely and professional manner, ensuring customer satisfaction and maintaining a positive company brand and image.

• Communicate with customers through various channels, including email, phone, text, and online review platforms to address concerns, provide updates, and resolve issues.

• Document all interactions, findings, and resolutions in our customer relationship management (CRM) system, maintaining accurate and up-to-date records.

• Support fraud, waste, and abuse review through clinical claim and provider-signal analysis, including case documentation and referral preparation.

• Identify opportunities for process improvements and recommend changes to enhance the overall member experience.

• Assist in the development and maintenance of standard operating procedures (SOPs) and best practices for the department.

• Participate in ongoing training and development opportunities to stay current on industry trends, best practices, and company policies.

• Perform additional tasks and duties as assigned by the management team.

Qualifications

• Bachelor's degree in business, communications, or a related field, or equivalent work experience.

• Minimum of 3 years of experience in customer service, with a focus on research, problem-solving, and issue resolution; dental, vision, or health insurance claims experience preferred.

• Working knowledge of dental terminology and CDT dental procedure coding, and familiarity with clinical claim-adjudication concepts such as dental necessity, frequency and age limitations, waiting periods, and missing-tooth provisions.

• Experience reviewing clinical documentation, dental records, radiographs, or EOBs — for example, in a dental front/back office, dental billing and coding, or dental/health insurance claims role.

• Ability to interpret clinical denial rationale and explain it to members in clear, non-technical language.

• Dental coding or clinical certification a plus (e.g., Certified Dental Coder (CDC), RDA/CDA, or a claims/coding certification).

• Strong analytical and research skills, with the ability to identify patterns and root causes of complex issues.

• Excellent verbal and written communication skills, with a focus on empathy, professionalism, and active listening.

• Demonstrated ability to work collaboratively with cross-functional teams and build positive relationships.

• Proficiency in product knowledge and using CRM systems and standard office software, including Microsoft Office Suite and Google Workspace.

• Strong organizational and time management skills, with the ability to prioritize tasks and manage multiple projects simultaneously.

• Demonstrated commitment to providing exceptional customer service and maintaining a positive company reputation.

NCD Benefits:

• Company-paid health, dental, life, and disability insurance

• 401(k) with employer match

• Opportunity for professional development

• Work from home allowance and support

• Positive work environment

Equal Opportunity

NCD is an Equal Opportunity Employer. We are committed to building a team that reflects a variety of backgrounds, perspectives, and skills. We believe our differences make us stronger and help us better serve our members, agents, partners, and each other.

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