Avēsis
UtilizationManagementClinicalDentalProcessor
Neural analysis suggests this role is
optimal for Mid+ candidates.
“Utilization Management Clinical Dental Processor at Avēsis. Skills: process management, cross-functional coordination, vendor/stakeholder management, operational metrics, resource planning, continuous improvement, clinical judgment, reviewing dental x-rays, models, photos, and patient charts. Leverage professional judgment to evaluate service requests and determine their appropriateness.. Assess the necessity of treatments prior to provision.”
What You'll Achieve.
Complete 13 to 18 cases per hour, ensuring our contractual obligations are fulfilled.; Maintain a daily level of productivity in accordance with departmental requirements for production and quality standards.
Industry & Context.
Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task.
Mandatory overtime may be required during peak seasons., Access to reliable internet connection (25 MBPS upload/10 MBPS download speed) and an appropriate workspace are essential for success in this remote role.
What They're Looking For.
Must Have
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, 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.
Nice to Have
X-Ray certification is highly preferred., Knowledge of Medicare, Medicaid, or commercial insurance, Experience with HCPCS, CPT, CDT, and ICD-10 coding
What You'll Do.
Leverage professional judgment to evaluate service requests and determine their appropriateness.
Assess the necessity of treatments prior to provision.
Apply national clinical criteria and maintain up-to-date knowledge of relevant laws
and organizational policies.
Utilize clinical judgment in evaluations.
Complete 13 to 18 cases per hour.
Complete clinical scripts.
Review patient histories.
Import supporting documentation into our internal system.
Conduct reviews of prior authorizations by providers.
Determine cases of recommended treatment in accordance with Avesis UM procedural guidelines.
Refer cases to Clinical Director or consultant for professional review of clinical denials.
Ensure that the right systems
and measurements are in place to assist with accurate clinical determinations.
Understand and uphold Avesis’ policies and obligations relative to the UM reviews required by each client contract.
Document approval decisions for treatment in accordance with prescribed UM department procedural guidance.
Forward applicable files to the client health plan as required by each contract.
Provide recommendations on department policies
Evaluate and suggest changes as necessary to optimize processes and efficiencies.
Work in partnership with Avēsis personnel to improve system efficiency and collaborate on complex barriers that arise.
Maintain a daily level of productivity in accordance with departmental requirements for production and quality standards.
Maintain effective intradepartmental communications through sharing of plans
general company news and other information through informal and actively participates in routine departmental meetings.
Other Duties as assigned.
How You'll Work.
Team & Collaboration
Work in partnership with Avēsis personnel to improve system efficiency and collaborate on complex barriers that arise.; Maintain effective intradepartmental communications through sharing of plans, general company news and other information through informal and actively participates in routine departmental meetings.; 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.; Collegiality: building relationships on company-wide, approachable, and helpful, ability to mentor and support team growth.; 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.
Communication Scope
Ability to convey information and engage an audience in a professional setting.; Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing.; reading, writing, and professional communication skills
Full Job Description
# **Join us for an exciting career with the leading provider of supplemental benefits!** O**ur 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 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:** * 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 n
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