The Dental Consultant reviews claims based on medical necessity, in accordance with market contracts, evaluate appeals, counsel providers, identify providers with aberrant utilization patterns, provide clinical support for provider outreach, and act as a clinical SME (or liaison) for internal entities.
PRIMARY JOB RESPONSIBILITIES:
- 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 determine if proper documentation has been obtained to deny claim.
- Make further recommendations, request additional information, review charts, and make revised or reiterate claim decision.
- Reviews authorization requests for anesthesia and rendering decision on medical necessity.
- Review and render decisions on all orthodontic claims for handicapping malocclusions specific to each Market contract.
- Communicate claim review outcome to participating Dentists, plan members, and Health Plans.
- Facilitate and give Provider orientations.
- Represent DentaQuest in a professional manner at all times.
- Communicate to management ways to improve processes and productivity of company.
- Develop a full understanding 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.
- Develop knowledge and understanding of state and federal dental regulations, and proactively alert DentaQuest staff of changes that are taking place.
- Provide leadership and education in the provider community on the dental program; provide recommendations in managing the dental program efficiently and effectively.
- Represent DentaQuest in a professional manner for the market, including meetings associated with the provider community.
- Proactively seek out opportunities to speak on the benefits of Medicaid and Medicare dental programs.
- Identify community opportunities for DentaQuest to participate within, including, but not limited to: health fairs, dental screenings, back to school programs, etc.
- Develop an understanding of the oral health wellness and outreach programs DentaQuest offers, working closely with DentaQuest Dental Consultants and staff.
- Review dental cases to represent DentaQuest 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 DentaQuest business processes.
- Recruit qualified providers for the network.
- Other duties as assigned.
- Graduate of an accredited Dental School (D.D.S. or D.M.D).
- Maintain an unrestricted dental license. Knowledge of general dentistry.
- Efficient PC skills. Ability to use analytical/presentation tools such as Excel and PowerPoint.
- Organizational and time management skills.
- Ability to work with a team and independently to complete assigned tasks without supervision.
- Ability to make independent determinations on all 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
- 5 years of clinical experience preferred.
- Orthodontic experience a plus
- Incumbent must be able to communicate effectively.
- Requires overall light physical effort (up to 25lbs.)
- Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer).
- Ability to travel or move about within and outside serviced facilities required.
- Incumbent works primarily in either a private or shared office environment