Utilization Management Clinical Dental Processor

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess dental x-rays and related documentation to determine the medical necessity for prior authorizations.

• Conduct initial reviews of medical necessity based on member eligibility and the services covered by client contracts.

• Utilize clinical criteria and evidence-based guidelines to make decisions on the approval or denial of requested services.

• Review service requests to evaluate the appropriateness of treatment prior to provision.

• Implement national clinical criteria while staying informed about relevant laws, regulations, and organizational policies.

• Process between 13 to 18 cases per hour.

• Complete clinical scripts and assess patient histories.

• Input supporting documentation into the internal system.

• Perform provider prior-authorization reviews in accordance with Avesis UM procedural guidelines.

• Escalate cases involving clinical denials to the Clinical Director or a consultant.

• Document decisions regarding treatment approvals and send relevant files to client health plans.

• Suggest changes to policies, objectives, and initiatives to enhance processes and efficiency.

• Work collaboratively with Avēsis personnel to address system efficiency and complex barriers.

• Maintain daily productivity, output, and quality standards.

• Engage in departmental communications, meetings, monthly check-ins, and bi-weekly touch bases.

• Ensure confidentiality and secure handling of Avēsis and customer information.

⛳️ Requirements

• A High School Diploma or equivalent is required.

• A minimum of 2 years of experience as a Dental Assistant or Dental Hygienist is required.

• A Dental Assistant certificate or 2 years of chairside assisting is required.

• At least 2 years of experience reviewing dental x-rays, models, photos, and patient charts is required.

• Proficiency in Microsoft Office and other Windows-based applications is necessary.

• Strong skills in reading, writing, and professional communication are essential.

• Ability to manage multiple tasks and prioritize work effectively.

• Adaptability to handle changing priorities and multiple tasks.

• Effective time management and organizational skills are required.

• A reliable internet connection with upload speeds of 25 MBPS and download speeds of 50 MBPS is necessary.

• An appropriate workspace for remote work is required.

• X-Ray certification is highly desirable.

• Knowledge of Medicare, Medicaid, or commercial insurance is preferred.

• Experience with HCPCS, CPT, CDT, and ICD-10 coding is preferred.

🏝️ Benefits

• Eligibility for benefits, bonuses, and commissions may apply.

• Comprehensive medical, dental, supplemental health, life, and vision coverage for you and your dependents with no waiting period.

• Life and disability insurance.

• 401(k) plan with company matching.

• Tuition assistance offered.

• Paid parental leave available.

• Backup family care services provided.

• Flexible time off policy.

• Flexible dress code policy.

• Flexible work location policy.

• Employee Resource Groups that support inclusion and diversity.

• Opportunities for professional development through skill-building and leadership training.

• Philanthropic and volunteering opportunities available.

• A dynamic, modern work environment that promotes collaboration and creativity.