Job Description JOB SUMMARY: The Lead Clinical Review Specialist will organize and communicate daily workload to ensure turn-around times are met for all markets. In addition will evaluate and document coverage requirements to ensure the system and the Clinical Review Specialist are processing authorizations correctly. JOB RESPONSIBILITIES: Facilitate resolutions to internal and external clinical issues. Conduct round robins for new DentaQuest employees. Update Utilization Management Manager on complaints and issues from clients, providers and internal staff. Review daily market reports and update determinations. Prioritize and assure compliance with authorization turnaround times and adjudication deadlines. Communicate authorization review outcome to participating Dentists, plan members, and Health Plans. Review and pre-authorize major dental services based on medical necessity and eligibility, in accordance to contract language. 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. Work collaboratively with system support team to provide information and specifications on any new or existing market reports or edits. Attend market meetings. Represent DentaQuest in a professional manner at all times. Communicate to management ways to improve processes and productivity of company. Assist with administrative duties as assigned. Adhere to DentaQuest business processes. Other duties as assigned. Required Skills Great interpersonal skills Ability to work independently Excellent oral and written communication skills Proficient PC skills (Word, Excel, Access) Ability to prioritize and organize multiple tasks Ability to remain organized with multiple interruptions Required Experience Previous 6 months experience as a Clinical Review Specialist or equivalent leadership experience. High School Diploma or equivalent. 2 years of dental assisting experience or degree in dental field. Ability to read and interpret x-rays, dental models, photos, and\/or patient charts. Knowledge of telephone systems.
Website : http://www.dentaquest.com