Clinical Review Specialist Market Lead

Location: Milwaukee, Wisconsin, United States

Notice

This position is no longer open.

Remote Opportunity: 0

Requisition Number: 3627

Position Title: Clinical Review Specialist Market Lead

External Description:

JOB SUMMARY:

Organize and communicate daily workload assignments’ to ensure turn-around times are met for all markets. Evaluate and document coverage requirements to ensure the system and the Clinical Review Specialists are processing authorization correctly.

PRIMARY JOB RESPONSIBILITIES:

• Monitor department Windward queues and staff by primarily using the Claim Inventory Report in Windward to assure turnaround times are being met. Maintain daily spreadsheet of inventory to be completed.
• Prioritize and assure compliance with authorization turnaround times and payment deadlines.
• Identify, troubleshoot, research and analyze issues and trends and communicate them to management.
• Identify areas that require additional training or education and collaborate with clinical trainer to implement a plan of action.
• Attend and participate in new client and/or new business implementation meetings as well as market meetings.
• Present on departmental process and procedures to internal and external customers.
• Facilitate meetings and/or conference calls regarding authorizations or clinical topics with cross functional groups and/or providers.
• Facilitate resolutions to internal and external clinical issues.
• Address quality issues identified during clinical audits with clinical review specialists.
• Complete monthly one on one meetings with each Clinical Review Specialist
• Complete monthly team meetings for direct reports
• Backup Workflow Coordinator role as needed.
• Recommend any policy, procedure, or technical changes required in workflow or in Windward that are required to maintain turnaround times.
• Read, interpret and analyze 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.
• Review, interpret and analyze requests for orthodontic prior authorizations.
• Ability to review, authorize and calculate payments on orthodontic continuation of care cases.
• Evaluate contract changes and update Clinical Review Specialist documentation to ensure proper clinical decisions are made.
• Evaluate contract implementation/changes and verify the system is processing properly. Document system problems and notify appropriate departments, validate system implementation and /or corrections.
• Make corrections to determinations to ensure accurate and timely mailing of correspondence.
• Update Utilization Management Leadership on complaints and issues from clients, providers and internal staff.
• Conduct round robins for new DentaQuest employees.
• Update Utilization Management Manager on complaints and issues from clients, providers and internal staff.
• Communicate to management ways to improve processes and productivity of company.
• Communicate to team member’s supervisor actions that need to be taken to ensure claims standards and department policies are being met.
• Represent DentaQuest in a professional manner at all times.
• Adhere to DentaQuest business processes.
• Other duties as assigned.

JOB REQUIREMENTS:

• Minimum 2 years’ experience as a Clinical Review Specialist or equivalent leadership experience.
• High School Diploma or equivalent.
• Minimum of 4 years of dental assisting experience , degree in dental field or other related experience.
• Ability to read and interpret x-rays, dental models, photos, and/or patient charts.
• Great interpersonal skills.
• Ability to work independently.
• Excellent oral and written communication skills.
• Excellent 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.

PHYSICAL DEMANDS:

• Ability to communicate in an active office environment.
• Ability to efficiently operate all job related office equipment.
• Ability to communicate via telephone.
• Ability to sit for 75% of an 8 hour work day.

City: Milwaukee

State: Wisconsin

Community / Marketing Title: Clinical Review Specialist Market Lead

Company Profile:

We believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system – from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.

Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it. 

To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and delivering measurable outcomes for the people we serve.

The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.

Company Profile Job:

At DentaQuest, we believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system – from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.

Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it. 

To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and delivering measurable outcomes for the people we serve.

The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.

Location_formattedLocationLong: Milwaukee, Wisconsin US

CountryEEOText_Description: In accordance with our Compliance Plan, employees must conduct business in accordance with applicable laws, regulations, professional standards and ethical standards and report potential compliance or ethical issues to manager or Compliance Officer. Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please see Human Resources for additional information regarding this Program. Equal Employment Opportunity Statement: We are committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, or sexual orientation.

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