Job Description
Description:
The Clinical Review Specialist provides timely and accurate review and authorization of dental services based on eligibility and contract requirements.
Successful completion of the Clinical Review Specialist training program.
Read, interpret, and evaluate 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 Team Leads to coordinate workload to ensure all work is completed daily.
Requirements:
High School Diploma or equivalent.
1 year dental assisting experience.
Previous dental insurance experience a plus.
Ability to read and interpret x-rays, dental models, photos, and/or patient charts.
Good interpersonal skills.
Ability to work without supervision.
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.
Benefits:
Excellent benefits and wellness programs to support the three pillars of well-being mental, physical and financial.
Generous vacation and sick time.
Market-leading paid family, parental and adoption leave.
Partially-paid sabbatical program.
Medical plans.
Company paid life and AD&D insurance as well as disability programs.
Retirement and Stock Purchase programs including a 401(k) plan with an employer-paid match and employer-funded retirement account.
A flexible work environment with a friendly, caring, collaborative and inclusive culture.
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