Utilization Management Clinical Processor

Avesis

3d•$18 - $36•Remote

About The Position

Join us for an exciting career with the leading provider of supplemental benefits! Our Promise Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards. As a Utilization Management Clinical Dental Processor, you will leverage your dental clinical expertise to review dental x-rays and documentation, assessing medical necessity for prior authorizations. You will perform initial reviews of medical necessity cases, ensuring they comply with member eligibility and the covered services outlined in each client contract. The UM (Utilization Management) Department supports our clients and company through utilizing clinical criteria to approve or deny a service based on the authorization. The UM Clinical Dental Processor plays a crucial role in ensuring that healthcare services provided to members are appropriate, efficient, and effective. They achieve this by utilizing clinical criteria and evidence-based guidelines to evaluate the necessity and appropriateness of treatments As a Utilization Management Clinical Dental Processor, you will leverage your professional judgment to evaluate service requests and determine their appropriateness, assessing the necessity of treatments prior to provision. You will apply national clinical criteria and maintain up-to-date knowledge of relevant laws, regulations, and organizational policies, utilizing clinical judgment in your evaluations. To meet our client standards, you will be required to complete 13 to 18 cases per hour, ensuring our contractual obligations are fulfilled. Additionally, you will complete clinical scripts, review patient histories, and import supporting documentation into our internal system. Work hours will be determined by your manager and may vary based on location, department needs, and workflow. Mandatory overtime may be required during peak seasons. Functional Competencies: Conducts reviews of prior authorizations by providers -- determining cases of recommended treatment in accordance with Avesis UM procedural guidelines or refers the case to Clinical Director or consultant for professional review of clinical denials. Ensures that the right systems, processes, and measurements are in place to assist with accurate clinical determinations are rendered Understands and upholds Avesis’ policies and obligations relative to the UM reviews required by each client contract. Documents approval decisions for treatment in accordance with prescribed UM department procedural guidance, and forwards applicable files to the client health plan as required by each contract. Provide recommendations on department policies, objectives, and initiatives. Evaluate and suggest changes as necessary to optimize processes and efficiencies. Works in partnership with Avēsis personnel to improve system efficiency and collaborate on complex barriers that arise. Maintains a daily level of productivity in accordance with departmental requirements for production and quality standards. Maintains effective intradepartmental communications through sharing of plans, general company news and other information through informal interactions; and actively participates in routine departmental meetings. Other Duties as assigned. Core Competencies: Maintain strict confidentiality of information related to Avēsis and its customers, following our information security policies. This obligation continues even after employment ends, including secure handling of data and access management Must be self-motivated and highly organized with the ability to work autonomously without direct supervision Ability to convey information and engage an audience in a professional setting. Ability to operate in a fast-paced environment under tight deadlines and deliver high-quality work consistently. Use virtual platforms like Teams and Microsoft Outlook for collaboration. Participate in regular monthly check-ins and bi-weekly department touch bases for market updates and team alignment. Behavioral Competencies: Collegiality: building strong relationships on company-wide, approachable, and helpful, ability to mentor and support team growth. Initiative: readiness to lead or take action to achieve goals. Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing. Member-focused: going above and beyond to make our members feel seen, valued, and appreciated. Detail-oriented and thorough: managing and completing details of assignments without too much oversight. Flexible and responsive: managing new demands, changes, and situations. Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task. Integrity & responsibility: acting with a clear sense of ownership for actions, decisions and to keep information confidential when required. Collaborative: ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.

Requirements

High School Diploma or equivalent required.
2+ years of either Dental Assistant or Dental Hygienist required.
Dental Assistant certificate or 2 years of chair side assisting required.
2 years of experience reviewing dental x-rays, models, photos, and patient charts required.
Proficiency with Microsoft Office and other Windows-based applications
Strong reading, writing, and professional communication skills
Ability to manage multiple tasks and prioritize work
Adaptability to handle multiple and changing priorities
Effective time management and organizational skills
Access to reliable internet connection (25 MBPS upload/50 MBPS download speed) and an appropriate workspace are essential for success in this remote role.

Nice To Haves

X-Ray certification highly desired
Knowledge of Medicare, Medicaid, or commercial insurance
Experience with HCPCS, CPT, CDT, and ICD-10 coding

Responsibilities

Conducts reviews of prior authorizations by providers -- determining cases of recommended treatment in accordance with Avesis UM procedural guidelines or refers the case to Clinical Director or consultant for professional review of clinical denials.
Ensures that the right systems, processes, and measurements are in place to assist with accurate clinical determinations are rendered
Understands and upholds Avesis’ policies and obligations relative to the UM reviews required by each client contract.
Documents approval decisions for treatment in accordance with prescribed UM department procedural guidance, and forwards applicable files to the client health plan as required by each contract.
Provide recommendations on department policies, objectives, and initiatives.
Evaluate and suggest changes as necessary to optimize processes and efficiencies.
Works in partnership with Avēsis personnel to improve system efficiency and collaborate on complex barriers that arise.
Maintains a daily level of productivity in accordance with departmental requirements for production and quality standards.
Maintains effective intradepartmental communications through sharing of plans, general company news and other information through informal interactions; and actively participates in routine departmental meetings.
Other Duties as assigned.

Benefits

Competitive compensation package.
Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
Life and disability insurance.
A great 401(k) with company match.
Tuition assistance, paid parental leave and backup family care.
Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
Employee Resource Groups that advocate for inclusion and diversity in all that we do.
Social responsibility in all aspects of our work. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.

Stand Out From the Crowd

Upload your resume and get instant feedback on how well it matches this job.

Upload and Match Resume