Clinical Review Support Specialist

Sun Life•Milwaukee, WI

17h

About The Position

The Clinical Review Specialist I provides timely and accurate review and authorization of dental services based on eligibility and contract requirements. Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide. At Sun Life, we're driven by our Purpose: helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful. When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives. DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

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

Successful completion of the Clinical Review Specialist training program
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