Sr. Clinical Dental Advisor, DentaQuest

Sun Life•Wellesley, MA

1d•Hybrid

About The Position

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work in the contiguous states plus AK. The opportunity: The Sr. Clinical Dental Advisor acts as the primary professional authority on service authorizations and medical necessity determinations. This role ensures that dental services requested by providers comply with state and federal Medicaid regulations, evidence-based standards and dental plan policies. The Sr. Clinical Dental Advisor maintains the highest level of productivity and quality in making service authorization decisions.

Requirements

Must hold a DDS or DMD degree with an active Oregon dental license and extensive clinical experience.
Deep understanding of Oregon Administrative Rules (OARs) and CDT coding systems
Ability to interpret complex clinical data and radiological evidence to make defensible authorization decisions
Strong interpersonal skills.
Ability to work independently.
Excellent oral and written communication skills for writing technical correspondence and testifying in hearings
Ability to prioritize and organize multiple tasks.
Ability to remain organized with multiple interruptions.
Required to attend additional training as requested/deemed necessary.

Responsibilities

Evaluate dental requests (including x-rays and clinical notes) for appropriateness, completeness, and adherence to Oregon Administrative Rules (OARs); make service authorization decisions.
Evaluate requests from General Dentists for specialty services (e.g. endodontics, oral surgery) to confirm the clinical basis and compliance with dental plan benefits.
Act as a “scope of practice” auditor to prevent unnecessary specialist referrals for procedures the referring General Dentist is contractually or professionally capable of performing, thereby managing utilization costs and member access.
Use professional judgment and evidence-based criteria to approve or deny service requests.
Communicate directly with dental providers to clarify documentation or provide clinical justification for treatment alternatives.
Represent dental plan in administrative hearings as expert witness.
Participate in the dental plan Peer Review and Credentialing committee.
Expert in specific market nuances.
Consistently exceed productivity requirements.
Identify areas for process improvements within the department.
Other duties as assigned.