Technical Consultant role focused on customer service and technical negotiations at Dimensional Brasil. Managing client relationships, logistics, and process proposals.
About the role
- Sr. Clinical Dental Consultant at DentaQuest reviewing claims based on medical necessity, evaluating appeals, and providing clinical aid for provider outreach. Focused on improving oral health access and quality care.
Responsibilities
- Reviews claims based on medical necessity, in accordance with market contracts
- Evaluate appeals and identify if proper documentation has been obtained to deny claim
- Makes further recommendations, request additional information, review charts, and make revised or reiterate claim decision
- Reviews authorization requests for anesthesia and rendering judgement on medical necessity
- Review and render conclusions on all orthodontic claims for handicapping malocclusions specific to each Market contract
- Communicate claim review outcome to participating Dentists, plan members, and Health Plans
- Facilitate and give Provider orientations
- Communicate to management ways to improve processes and productivity of company
- Develop a full comprehension of the administration of the dental program, including, but not limited to: benefit and authorization requirements for Plans and/or States
- Develop knowledge and understanding of state and federal dental regulations, and proactively alert staff of changes that are taking place
- Provide guidance and education in the provider community on the dental program; provide recommendations in managing the dental program efficiently and effectively
- Represent the company in a professional manner for the market, including meetings associated with the provider community
- Proactively seek out opportunities to speak on the benefits of Medicaid and Medicare dental programs
- Identify community opportunities for the company to participate within, including, but not limited to: health fairs, dental screenings, back to school programs, etc.
- Develop an understanding of the oral health wellness and outreach programs offered, working closely with Dental Consultants and staff
- Review dental cases to represent the company at fair hearings, as needed
- Establish relationships with dental associations and key stakeholders in the surrounding region, helping to solidify new business in other states
- Adhere to business processes
- Recruit qualified providers for the network
- Other duties as assigned
Requirements
- Graduate of an accredited Dental School (D.D.S. or D.M.D)
- Orthodontic experience a plus
- Maintain an unrestricted dental license
- Knowledge of general dentistry
- Efficient PC skills
- Ability to use analytical/presentation tools such as Excel and PowerPoint
- Organizational and time management skills
- Ability to work with a team and independently to complete assigned tasks without supervision
- Ability to make independent determinations on all types of dental claims
- Excellent written and verbal communication skills
- Ability to distinguish between multiple market benefits
- Ability to prioritize and organize multiple tasks
- Ability to remain organized with multiple interruptions
- Networking and Negotiation skills required
- Ability to travel as needed
- Required to attend additional training as requested/deemed necessary
Benefits
- Generous vacation and sick time
- Market-leading paid family, parental and adoption leave
- Medical coverage
- Company paid life and AD&D insurance
- Disability programs
- Partially paid sabbatical program
- 401(k) employer match
- Stock purchase options
- Employer-funded retirement account
- Flexible, inclusive and collaborative work environment
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