Utilization Management Clinical Dental Processor

🔥 7 minutes ago

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Avēsis

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1978

🛡️ Insurance

⚕️ Healthcare Insurance

🧘 Wellness

Insurance • Healthcare Insurance • Wellness

Avēsis is a company dedicated to providing comprehensive specialty benefits focused on improving access, equity, and health outcomes. Specializing in dental and vision plans, Avēsis offers flexible, affordable, and outcome-focused oral health benefits as well as vision plans that connect eye health to overall well-being. With over 40 years of experience, Avēsis is committed to personalized care and building community health networks to service government partners, commercial providers, employers, and brokers. Avēsis operates as a wholly owned subsidiary of Guardian, and leverages tailored network and product solutions to deliver accessible quality care to members, while also administering Medicaid, Medicare, and other essential benefits programs.

📋 Description

• Review dental x-rays and documentation to assess medical necessity for prior authorizations • Perform initial medical necessity reviews based on member eligibility and covered services in client contracts • Use clinical criteria and evidence-based guidelines to approve or deny requested services • Evaluate service requests and determine treatment appropriateness before provision • Apply national clinical criteria and maintain knowledge of relevant laws, regulations, and organizational policies • Complete 13 to 18 cases per hour • Complete clinical scripts and review patient histories • Import supporting documentation into the internal system • Conduct provider prior-authorization reviews according to Avesis UM procedural guidelines • Refer cases involving clinical denials to the Clinical Director or consultant • Document treatment approval decisions and forward applicable files to client health plans • Recommend policy, objective, and initiative changes to improve processes and efficiency • Collaborate with Avēsis personnel on system efficiency and complex barriers • Maintain daily productivity, production, and quality standards • Participate in departmental communications, meetings, monthly check-ins, and bi-weekly touch bases • Maintain confidentiality and secure handling of Avēsis and customer information

🎯 Requirements

• High School Diploma or equivalent required • 2+ years of experience as a Dental Assistant or Dental Hygienist required • Dental Assistant certificate or 2 years of chairside assisting required • 2 years of experience reviewing dental x-rays, models, photos, and patient charts required • Proficiency with Microsoft Office and other Windows-based applications • Strong 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 • Reliable internet connection with 25 MBPS upload and 50 MBPS download speed • Appropriate workspace for remote work • X-Ray certification highly desired • Knowledge of Medicare, Medicaid, or commercial insurance preferred • Experience with HCPCS, CPT, CDT, and ICD-10 coding preferred

🏖️ Benefits

• Benefits, bonuses, and commission eligibility may apply • Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period • Life and disability insurance • 401(k) with company match • Tuition assistance • Paid parental leave • Backup family care • Flexible time off • Flexible dress code policy • Flexible work location policy • Employee Resource Groups supporting inclusion and diversity • Professional development through skill-building and leadership development • Philanthropic and volunteering opportunities • Dynamic, modern work environments promoting collaboration and creativity