|Part-Time 20 hours a week
Which days worked are flexible but must be available until 6 pm on days worked.
The Dental Liaison will perform the initial screening claims requiring utilization review. Liaisons will not interpret or evaluate clinical information, but will review each procedure request according to the specific clinical criteria/guideline. The role of the Liaison is limited to the collection and transfer of non-clinical data and the acquisition of structured clinical data.
If the clinical criteria/guidelines are met, the Liaisons make a review determination by indicating the approval decision on the consultant notepad. If the clinical criteria/guidelines aren’t met, the liaison refers the claim to the appropriate dental consultant for review. Adverse benefit determinations are not issued by the liaisons.
Title of supervisor to this position: Manager-Dental Consultant Review
Titles of those reporting directly to this position: None
• Review each procedure request according to the specific clinical criteria/guideline.
• Approve claims that meet the liaison guideline and refer all others to the dental consultants. Does not evaluate or interpret clinical information.
• Review provider practice patterns that are outside of the norm.
• Apply policy provisions and knowledge of company philosophy to ensure compliance with the contract, legal requirements and guidelines established by various state and federal regulations, URAC standards and “Best Practices and Procedures” within Customer Connections and Operations. Partner with Group Compliance to assure requirements are implemented appropriately.
• Proficient in using the claims/image system and various sub-systems. Knowledge of various contracts including PPO, special marketing arrangements and service guarantees. The individual must be sensitive to arrangements requiring them to represent strategic alliances.
• Contact dental offices to interpret procedures and obtain information and/or supporting documentation.
• Serve as liaison between the Customer Connections associates and dental consultants.
• Analyze claim discrepancies to ensure claim is processed accurately and make appropriate adjustments.
• Screen claims to determine areas of associate development and possible system enhancements.
• .Assist the Dental Liaison Records Specialist when needed
• Assist in the mentoring of associates as assigned by department management.
• Additional responsibilities as assigned by department management.
• Evaluate adjudication process to determine if system logic is appropriate.
Required Knowledge and Skills:
• Post-secondary training or two years clinical experience either as a Dental Assistant or Dental Hygienist
• Must have completed radiology training.
• Strong initiative for assessing situations.
• Excellent communication skills
• Problem solving and analytical skills are required to determine best course of action.
• Adaptive to change and improvement
• Ability to establish relations with a diverse group of people.
• Proficient use of personal computer system and keyboarding skills.
Normal office environment
Occasional travel to other locations