Clinical Review Specialist I

JOB SUMMARY: The Clinical Review Specialist I provides timely and accurate review and authorization of dental services based on eligibility and contract requirements.

PRIMARY JOB 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

JOB 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

Preferred:

• Previous dental insurance experience a plus

PHYSICAL DEMANDS: 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.

Webelieve that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system - from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.

Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it.

To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and deliveringmeasurableoutcomes for the people we serve.

The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.