[Hiring] Utilization Management Clinical Dental Processor @Avesis

Role Description

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.

• Conducts reviews of prior authorizations by providers.
• Determines 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.
• 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.
• Provides recommendations on department policies, objectives, and initiatives.
• Maintains a daily level of productivity in accordance with departmental requirements for production and quality standards.
• Maintains effective intradepartmental communications through sharing of plans and actively participates in routine departmental meetings.
• Other duties as assigned.

Qualifications

• High School Diploma/GED.
• Dental Assistant or Dental Hygienist required.
• Dental Assistant certificate or 2 years of chair side assisting.
• 1-2 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/10 MBPS download speed) and an appropriate workspace are essential for success in this remote role.

Requirements

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

Benefits

• Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
• 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.