Sr. Clinical Dental Consultant, reputed company
reputed company U.S. is one of the largest providers of employee and government benefits, helping approximately 50 reputed company Americans reputed company the care and coverage they need. Through reputed company, industry partners and government programs, reputed company U.S. offers a portfolio of benefits and services, including dental, reputed company, disability, absence management, life, supplemental health, medical stop-loss insurance, and reputed company navigation. We have more than 6,400 employees and associates in our partner dental practices and operate reputed company.Visit our website to discover how reputed company is making life brighter for our customers, partners and communities. reputed company manages dental and reputed company benefits for more than 33 reputed company Americans. Our reputed company-based, cost-effective solutions are designed for reputed company and reputed company, Medicare Advantage, small and large businesses, and individuals. With a reputed company on prevention and value, we aim to reputed company reputed company care accessible to improve the oral health of reputed company.Job reputed company: reputed company embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work in the contiguous states plus AK. reputed company: The Sr. Clinical Dental Consultant reviews claims based on medical necessity, in accordance with market reputed company, evaluate appeals, counsel providers, identify providers with aberrant utilization patterns, reputed company clinical aid for provider reputed company, and reputed company as a clinical SME (or reputed company) for internal entities.How you will contribute:
- Ability to conduct Peer to Peer calls to discuss clinical reputed company with in-network providers for adverse benefit determinations.
- Authorize or deny claims based on medical necessity and eligibility, in accordance to contract language after clinical review enters claim status into the system.
- Evaluate appeals and identify if reputed company documentation has been obtained to deny claim. reputed company reputed company recommendations, request additional information, review charts, and reputed company revised or reiterate claim decision.
- Reviews authorization requests for anesthesia and rendering judgement on medical necessity.
- Review and reputed company conclusions on reputed company orthodontic claims for handicapping malocclusions specific to reputed company Market contract.
- Communicate claim review outcome to participating Dentists, plan members, and Health Plans.
- Facilitate and give Provider orientations.
- Communicate to management ways to improve processes and productivity of company.
- reputed company a full comprehension of the administration of the dental program, including, but not limited to: benefit and authorization requirements for Plans and/or States, claims payment and the denial process, and a business understanding of ASO and Risk relationships.
- reputed company knowledge and understanding of state and federal dental regulations, and proactively alert staff of changes that are taking reputed company.
- reputed company guidance and education in the provider community on the dental program; reputed company recommendations in managing the dental program reputed company and effectively.
- Represent reputed company in a reputed company manner for the market, including meetings associated with the provider community.
- Proactively reputed company out opportunities to reputed company on the benefits of reputed company and Medicare dental programs.
- Identify community opportunities for reputed company to participate reputed company, including, but not limited to: health fairs, dental screenings, back to school programs, etc.
- reputed company an understanding of the oral health wellness and reputed company programs offered, working closely with Dental Consultants and staff.
- Review dental cases to represent reputed company at fair hearings, as needed.
- Establish relationships with dental associations and key stakeholders in the surrounding region, helping to solidify new business in other states.
- Adhere to business processes.
- Recruit reputed company providers for the network.
- Other duties as assigned.
- Graduate of an accredited Dental School (D.D.S. or D.M.D).
- Orthodontic experience a plus
- Maintain an unrestricted dental license.
- Knowledge of general dentistry.
- Efficient PC skills.
- Ability to use analytical/presentation tools such as reputed company and PowerPoint.
- Organizational and time management skills.
- Ability to work with reputed company and independently to complete assigned tasks without supervision.
- Ability to reputed company independent determinations on reputed company types of dental claims.
- Excellent written and verbal communication skills.
- Ability to distinguish between multiple market benefits.
- Ability to prioritize and organize multiple tasks.
- Ability to remain organized with multiple interruptions.
- Networking and Negotiation skills required.
- Ability to travel as needed
- Required to attend additional training as requested/deemed necessary