Clinical Review Support Specialist
About The Position
The Clinical Review Specialist I provides timely and accurate review and authorization of dental services based on eligibility and contract requirements. This role involves analyzing x-rays, models, and requests for major dental services to ensure medical necessity, client coverage, provider participation, and member eligibility align with contract language. The specialist will also resolve claim and prior authorization suspends that require UM Review, consistently meet productivity and audit score requirements, and communicate effectively with colleagues and leads to ensure daily workload completion. Additionally, the role requires knowledge of reference materials, responding to follow-ups, providing telephone customer service to providers regarding clinical issues, and performing peer clinical reviews.
Requirements
- High School Diploma or equivalent
- 1 year dental assisting experience
- Ability to read and interpret x-rays, dental models, photos, and/or patient charts
- Good interpersonal skills
- Ability to work independently
- Excellent oral and written communication skills
- Efficient PC skills (Word, Excel, Outlook)
- Ability to prioritize and organize multiple tasks
- Ability to remain organized with multiple interruptions
- Knowledge of telephone systems
- Ability to work in excess of 40 hours in a week
- Required to attend additional training as required/deemed necessary
Nice To Haves
- Previous dental insurance experience a plus
Responsibilities
- Provide timely and accurate review and authorization of dental services based on eligibility and contract requirements.
- Read, interpret and analyze x-rays, models and requests for major dental services based on medical necessity, client coverage, provider participation and member eligibility, in accordance with contract language.
- Resolve claim and prior authorization suspends that require UM Review.
- Consistently meet productivity requirements.
- Maintain audit score of 95% or greater.
- Pass the IRR quarterly.
- Communicate and work effectively with co-workers and Leads to coordinate workload to ensure all work is completed daily.
- Knowledge of reference materials and documentation that contain market nuances.
- Respond to follow-ups.
- Provide customer service via the telephone to providers regarding clinical issues.
- Other duties as assigned.
- Represent DentaQuest in a professional manner at all times.
- Adhere to DentaQuest business processes.
- Performs peer clinical reviews.
Benefits
- Generous vacation and sick time
- Market-leading paid family, parental and adoption leave
- Medical coverage
- Company paid life and AD&D insurance
- Disability programs
- Partially paid sabbatical program
- 401(k) employer match
- Stock purchase options
- Employer-funded retirement account
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
