Contract Opportunity: 6-months
Location: Remote - Must Reside in CA
The Dental Consultant utilizes clinical expertise of dental procedures and practices to adjudicate prior authorization requests and claims.
- Process and/or adjudicate claims or treatment authorization requests that require professional review; review supporting documentation and adjudicate by applying dental standards.
- Identify when additional information is necessary to make a claim or prior authorization determination and collaborate with internal and external parties to gather information where appropriate.
- Respond to inquiries from internal and/or external stakeholders regarding claim or prior authorization requests.
- Utilize best practices in identification of potential Fraud, Waste, and Abuse (FWA) issues and report any identified issues to the appropriate party for resolution.
- Process requests for re-evaluation.
- May review and analyze documentation related to patient quality-of-care complaints, state hearings, first level appeals, audits, Conlan cases, and maintain logs of resolved grievances as needed.
- Conduct or assist in developing seminars or training programs as needed.
- This list is not all-inclusive and you are expected to perform other duties as requested or assigned
- A Bachelor's degree or equivalent education
- A DDS or DMS degree from an accredited dental school.
- A minimum of 5 years experience working for a government of private sector healthcare payer similar in size, including a minimum of two years MMIS experience in a state of equivalent scope to CA
- The Dental Consultant shall be licensed by the State of California and license must be in good standing and current at the time of hire and remain current during the entirety of their employment
- A minimum of 10+ years clinical experience
- Active and unencumbered license and good standing with the Dental Licensing Board.
- Special training and/or professional certificates may be substituted for experience.
- Strong organizational/time management skills and multi-tasking abilities.
- Detail oriented with analytic and problem-solving abilities.
- Customer service, conflict management and dispute resolution skills.
- Knowledge of health care industry issues preferred.
- Knowledge of company products, policies, claims, eligibility and underwriting guidelines.
- Good standing with the Dental Licensing Board of the appropriate state.
- PC literacy required; MSOffice skills (Outlook, Word, Excel, PowerPoint).
- Regularly required to work standard office equipment (personal computer, photocopy machine, fax machine,
- Ability to work on a computer up to 7 hours a day.
- Regularly required to sit for long periods of time, and occasionally stand and walk.
- Regularly required to use hands to operate computer and other office equipment.
- Close vision required for computer usage. Occasionally required to stoop, kneel, climb and lift up to 25 pounds.
- Ability to maintain consistent, regular attendance.
- Ability to report to perform tasks in a physical work office environment.
- Ability to clearly present written information and findings.
- Ability to communicate concepts. Ability to interact well with co-workers and outside contacts.
- Strong organizational skills that reflect ability to perform and prioritize multiple tasks seamlessly with exact attention to detail
- Excellent analytical and problem-solving skills
- Excellent interpersonal, verbal, and written communication skills
- Proficiency with the Microsoft Office Suite, including Word, Excel, Outlook, etc.
- Ability to adapt quickly in a fast-paced environment
- Knowledge of Current Dental Terminology (CDT) codes, dental nomenclature, and industry trends
- Knowledge of company products, policies, claims, eligibility and underwriting guidelines
If this sounds like a fit for you, apply today!