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Part Time Dental Consultant - Utah

Company

Avesis, Incorporated
Address , Remote
Employment type PART_TIME
Salary
Expires 2023-07-30
Posted at 10 months ago
Job Description
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.
This position is an adjudication role in reviewing CHIP, Medicaid, Medicare Advantage, and commercial dental claims and preauthorization’s (all contracts Avesis manage). The role includes supporting Dental Program Management efforts to build and maintain network relationships in Utah, and effectively interact with control of fraud, waste, and abuse (FWA) activity under Compliance’s leadership and the Quality division within the company’s state sponsored dental programs and other government and commercial plans.
Essential Job Functions and Responsibilities:
Claim Review and Utilization Management
  • Consultant will access queues on Avēsis HIPAA compliant platform for online adjudication.
  • Consultant will be aware of the need to confirm eligibility for provided services and limitations based on plan guidelines.
  • Reviews Pre-treatment authorization services for determination of medical necessity within plan guidelines.
  • Consultant will regularly monitor queues for claims and prior authorizations in need of timely adjudication.
  • Processes and/or adjudicates claims or treatment authorization requests that require professional review; reviews supporting documentation and adjudication by applying dental standards
  • Pre-Auth Review
    • Processes and/or adjudicates claims or treatment authorization requests that require professional review; reviews supporting documentation and adjudication by applying dental standards
    • Reviews Pre-treatment authorization services for determination of medical necessity within plan guidelines.
    • Consultant will access queues on Avēsis HIPAA compliant platform for online adjudication.
    • Consultant will regularly monitor queues for claims and prior authorizations in need of timely adjudication.
    • Consultant must consistently meet Utah’s required turnaround times (TAT) specific to that state contract.
    • Consultant will be aware of the need to confirm eligibility for provided services and limitations based on plan guidelines.
  • Consultant must consistently meet Utah’s required turnaround times (TAT) specific to that state contract.
  • Reviews appeals as directed by State Dental Director.
  • Appeals
    • Reviews appeals as directed by State Dental Director.
    • Provider appeals committee attendance as requested by State Dental Director, or as needed.
  • Provider appeals committee attendance as requested by State Dental Director, or as needed.
  • Reviews services requiring post-treatment review to determine compliance with plan and clinical guidelines.
  • Post Service Reviews
    • Reviews services requiring post-treatment review to determine compliance with plan and clinical guidelines.
  • Audits/FWA
    • Consultant will review audit cases opened by compliance
  • Consultant will review audit cases opened by compliance
  • Peer-to-Peer through Quality Department
    • Performs peer-to-peer reviews by calling dental offices and dentists to discuss denials and their issues from claim submissions when required by the state or plan.
  • Performs peer-to-peer reviews by calling dental offices and dentists to discuss denials and their issues from claim submissions when required by the state or plan.
Supportive Role
  • Assist relevant departments in coordinating any determination decisions made from the Fair Hearing Meetings, as directed by State Dental Director.
  • State Fair Hearings
    • Support State Dental Director by reviewing scheduled Dental Utah’s Fair Hearing cases prior to the scheduled Fair Hearing Meeting, as directed by State Dental Director.
    • Support State Dental Director by providing clinical review and justification at the Fair Hearing Meetings, as directed by State Dental Director.
    • Assist relevant departments in coordinating any determination decisions made from the Fair Hearing Meetings, as directed by State Dental Director.
  • Support State Dental Director by providing clinical review and justification at the Fair Hearing Meetings, as directed by State Dental Director.
  • Support State Dental Director by reviewing scheduled Dental Utah’s Fair Hearing cases prior to the scheduled Fair Hearing Meeting, as directed by State Dental Director.
  • Support the Dental Director in review of Utilization Management, such as authorization, appeals, and claim reviews.
  • Provide support in tracking and trending provider activity and providing alerts to Avēsis concerning unusual practice patterns or potential abuses.
  • Review investigatory audits as directed by FWA/Compliance.
  • Support for UM and FWA
    • Support the Dental Director in review of Utilization Management, such as authorization, appeals, and claim reviews.
    • Assist in case reviews for clinical vendor oversight programs as well as clinical chart audit reviews.
    • Review investigatory audits as directed by FWA/Compliance.
    • Provide support in tracking and trending provider activity and providing alerts to Avēsis concerning unusual practice patterns or potential abuses.
  • Assist in case reviews for clinical vendor oversight programs as well as clinical chart audit reviews.
  • Serve as a clinical advisor to Avēsis committees including but not limited to Quality Improvement Committee, Dental Medicaid Utilization Management Committee, Dental Advisory Committee, Provider Appeals Committee, and others.
  • Provide support to the Dental Director for any state meetings or meetings with external advocacy groups or clients.
  • Support the Dental Director in Clinical and Quality programs and initiatives.
  • General Support
    • Support the Dental Director in Clinical and Quality programs and initiatives.
    • Serve as a clinical advisor to Avēsis committees including but not limited to Quality Improvement Committee, Dental Medicaid Utilization Management Committee, Dental Advisory Committee, Provider Appeals Committee, and others.
    • Provide support to the Dental Director for any state meetings or meetings with external advocacy groups or clients.
  • Participate with in-state Incidence Rate Ratio (IRR) chaired by the State Dental Director to assure continued adjudication calibration.
  • Clinical Calibration
    • Assist with the review of Policies and Procedures, guidelines, and clinical protocols, relative to the Dental programs, at least annually.
    • Participate with monthly state meetings chaired by the State Dental Director to bring line of sight on potential obstacles with the pre-authorizations, post reviews and/or appeals.
    • Participate with in-state Incidence Rate Ratio (IRR) chaired by the State Dental Director to assure continued adjudication calibration.
  • Participate with monthly state meetings chaired by the State Dental Director to bring line of sight on potential obstacles with the pre-authorizations, post reviews and/or appeals.
  • Assistance with decisions regarding referrals and to whom referrals should be made.
  • Assist with the review of Policies and Procedures, guidelines, and clinical protocols, relative to the Dental programs, at least annually.
  • Interaction with Avēsis Provider Relations Field Staff
    • Support office audits with Avēsis Provider Services Field Representatives, as needed.
    • Available to support fraud and abuse investigations with the FWA department.
    • Assistance with decisions regarding referrals and to whom referrals should be made.
  • Support office audits with Avēsis Provider Services Field Representatives, as needed.
  • Available to support fraud and abuse investigations with the FWA department.
  • Other duties as assigned.
Qualification Requirements:
Education:
  • DDS or DMD; holder of an active, unrestricted Utah dental license.
  • Dental Degree from an U.S. accredited Dental School.
Experience:
  • Residency in the state of Utah preferred.
  • A minimum of seven (7) years’ experience as a practicing dentist or dental specialist, with similar experience in the insurance industry.
Skills:
  • Clear communication skills.
  • Effective project management skills, especially time management.
  • Word processing: Ability to learn claim processing systems; Familiarity with Microsoft Suite (Excel, Outlook, Word).
Knowledge:
  • Knowledgeable of CDT code sets and descriptors is a plus.
  • AADC certification a plus.
  • Experience in delivery of dental care; knowledge of government and commercial plan designs and administration a plus.
  • Requires a diverse level of knowledge and experience in dentistry.
  • Travel: TBD
  • Possessing the clinical background to render consistent opinions on emerging dental trends, utilization review, dental plan coverage, claims policy and standards of care a plus.
  • Completion of credentialing process following NCQA guidelines.
We Offer
  • Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
  • Employee Resource Groups that advocate for inclusion and diversity in all that we do.
  • Life and disability insurance.
  • Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
  • 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.
  • Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
  • Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
  • Tuition assistance, paid parental leave and backup family care.
  • Competitive compensation package.
  • A great 401(k) with company match.
Equal Employment Opportunity
At Avēsis, We See You. We celebrate differences and are building a culture of inclusivity and diversity. We are proud to be an Equal Employment Opportunity employer that considers all qualified applicants and does not discriminate against any person based on ancestry, age, citizenship, color, creed, disability, familial status, gender, gender expression, gender identity, marital status, military or veteran status, national origin, race, religion, sexual orientation, or any other characteristic. At Avēsis, we believe that, to operate at the peak of excellence, our workforce needs to represent a rich mixture of diverse people, all focused on providing a world-class experience for our clients. We focus on recruiting, training and retaining those individuals that share similar goals. Come Dare to be Different at Avēsis, where We See You!