Avēsis
UtilizationManagementClinicalDentalProcessor
Neural analysis suggests this role is
optimal for Mid+ candidates.
“Utilization Management Clinical Dental Processor at Avēsis. Skills: Utilization Management, Clinical Dental Processing, Prior Authorization Reviews, Clinical Judgment. Evaluate service requests and determine appropriateness. Assess necessity of treatments prior to provision”
What You'll Achieve.
determine their appropriateness; assessing the necessity of treatments prior to provision; ensuring our contractual obligations are fulfilled; Maintains a daily level of productivity in accordance with departmental requirements for production and quality standards; achieve goals
Industry & Context.
Critical Thinking: effectively troubleshoot complex issues; problem solve; collaborate on complex barriers that arise
Mandatory overtime may be required during peak seasons, Access to reliable internet connection (25 MBPS upload/10 MBPS download speed), appropriate workspace are essential for success in this remote role
What They're Looking For.
Must Have
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, 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
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.
Evaluate service requests and determine appropriateness
Assess necessity of treatments prior to provision
Apply national clinical criteria and maintain knowledge
Complete 13 to 18 cases per hour
Complete clinical scripts and review patient histories
Import supporting documentation into internal system
Conduct reviews of prior authorizations by providers
and measurements are in place
Upholds Avesis’ policies and obligations
Documents approval decisions for treatment
Provide recommendations on department policies
Evaluate and suggest changes to optimize processes
Maintains a daily level of productivity
Maintains effective intradepartmental communications
Maintain strict confidentiality of information
Work autonomously without direct supervision
Convey information and engage an audience
Operate in a fast-paced environment
Use virtual platforms like Teams and Outlook
How You'll Work.
Team & Collaboration
Cross-functional coordination; Works in partnership with Avēsis personnel; Maintains effective intradepartmental communications; Participate in regular monthly check-ins; Participate in bi-weekly department touch bases; building relationships on company-wide; Collaborative: ability to represent your own interests; being fair to those representing other or competing ideas
Communication Scope
professional communication skills; Ability to convey information; engage an audience in a professional setting; Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing
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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