The Dental Consultant utilizes clinical expertise in dental procedures and practices to adjudicate prior authorization requests and claims.
Responsibilities
Process and adjudicate claims or treatment authorization requests that require professional review by applying dental standards to supporting documentation.
Identify when additional information is needed to make a claim or prior authorization determination and collaborate with internal and external parties to obtain it.
Respond to inquiries from internal and external stakeholders regarding claims or prior authorization requests.
Apply best practices to identify potential fraud, waste, and abuse issues and report identified issues to the appropriate parties.
Process requests for re-evaluation of claims and authorizations.
Review and analyze documentation related to patient quality-of-care complaints, state hearings, first-level appeals, audits, and related cases, and maintain logs of resolved grievances as needed.
Develop and/or conduct seminars or training programs as needed.
Perform other related duties as requested or assigned.
Requirements
Bachelor s degree or equivalent education.
DDS or DMS degree from an accredited dental school.
Minimum of 10 years of clinical dental experience.
Minimum of 5 years of experience working for a government or private sector healthcare payer of similar size, including at least 2 years of MMIS experience.
Active, current, and unencumbered dental license in good standing with the appropriate state dental licensing board.
Strong organizational and time management skills with the ability to manage multiple tasks.
Detail-oriented with strong analytical and problem-solving abilities.
Customer service, conflict management, and dispute resolution skills.
Knowledge of the healthcare industry and current dental terminology (CDT) codes, dental nomenclature, and industry trends.
Proficiency with Microsoft Office (Outlook, Word, Excel, PowerPoint) and general PC literacy.
Ability to work on a computer for extended periods and operate standard office equipment.
Ability to sit for long periods and occasionally stand, walk, stoop, kneel, climb, and lift up to 25 pounds.
Ability to maintain consistent, regular attendance and perform tasks in an office environment.
Ability to clearly present written information and findings and communicate concepts effectively.
Ability to interact effectively with co-workers and external contacts.
Summary Qualification
Licensed dentist with extensive clinical experience and payer-side experience in claims and prior authorization review.
Proven ability to interpret and apply dental standards, CDT codes, and industry guidelines.
Strong analytical, organizational, and communication skills supporting effective claims adjudication and issue resolution.
Demonstrated experience collaborating with cross-functional teams and external stakeholders.
Skill
Advanced knowledge of dental procedures, practices, and standards of care.
Thorough understanding of claims processing, prior authorization, and appeal workflows.
Knowledge of CDT codes, dental nomenclature, and industry trends.
Proficiency in Microsoft Office applications and general computer skills.
Strong written and verbal communication skills.
Excellent organizational, time management, and multitasking abilities.
Analytical thinking, problem solving, and attention to detail.
Customer service orientation with effective conflict management and dispute resolution skills.
Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.
Numbers & Facts
Location
Rancho Cordova, CA
Skills
Adjudicationunmatched
Analysis Skillsunmatched
Best Practicesunmatched
Claims Processingunmatched
Clinical Medicineunmatched
Communication Skillsunmatched
Computer Skillsunmatched
Conflict Resolutionunmatched
Consultingunmatched
Cross-Functionalunmatched
Customer Service Managementunmatched
Customer Support/Serviceunmatched
Dentistryunmatched
Detail Orientedunmatched
Documentationunmatched
Governmentunmatched
Healthcareunmatched
Identify Issuesunmatched
Industry/Trade Analysisunmatched
Legalunmatched
Licensingunmatched
Lift/Move 25 Poundsunmatched
Microsoft Excelunmatched
Microsoft Officeunmatched
Microsoft Outlookunmatched
Microsoft PowerPointunmatched
Microsoft Wordunmatched
Multitaskingunmatched
Office Equipmentunmatched
Organizational Skillsunmatched
Patient Care Authorizationsunmatched
Presentation/Verbal Skillsunmatched
Problem Solving Skillsunmatched
Quality of Careunmatched
Seminarsunmatched
Standards of Careunmatched
Time Managementunmatched
Training Programunmatched
Writing Skillsunmatched
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