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Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.
The Utilization Management Clinical Processor will be responsible for timely and accurate review of medical necessity determinations for urgent and contractually required requests on a 24/7, 365-day basis ensuring federal, state, NCQA or contractual requirements are met. You will perform first level review of medical necessity cases based on a member’s eligibility and covered services outlined for each client contract. Under the direction of the supervisor, you are responsible for completing medical necessity reviews. Using clinical knowledge and experience, the Utilization Management Clinical Processor reviews the provider request for treatment, working closely with members and provider to collect all information necessary to perform a thorough medical necessity review.
The Utilization Management Clinical Processor will use his/her professional judgment to evaluate the request and ensure that services are appropriately approved. You will apply clinical criteria that is laid out per our national criteria set forth by our Clinical Dental Consultants. In addition, our chosen candidate will maintain current knowledge and understanding of and regularly apply the laws, regulations, and policies that pertain to the organizational business units and uses clinical judgment in their application.
The Utilization Management Clinical Processor will use his/her professional judgment to evaluate the request and ensure that services are appropriately approved. You will apply clinical criteria that is laid out per our national criteria set forth by our Clinical Dental Consultants. In addition, our chosen candidate will maintain current knowledge and understanding of and regularly apply the laws, regulations, and policies that pertain to the organizational business units and uses clinical judgment in their application.
Competencies:
Functional:

Conducts reviews of prior authorizations by providers

- - determining cases of recommended treatment in accordance with Avesis UM procedural guidelines or refers the case to Clinical Director or consultant for professional review of clinical denials.
- Understands and upholds Avesis’ policies and obligations relative to the UM reviews required by each client contract.
- Documents approval decisions for treatment in accordance with prescribed UM department procedural guidance, and forwards applicable files to the client health plan as required by each contract.
- Maintains a daily level of productivity in accordance with departmental requirements for production and quality standards.
- Maintains effective intradepartmental communications through sharing of plans, general company news and other information through informal interactions; and actively participates in routine departmental meetings.
- Other Duties as assigned.

Core:

• Ability to convey information and engage an audience in a professional setting.
• Provide recommendations on department policies, objectives, and initiatives. Evaluate and suggest changes as necessary to optimize processes and efficiencies. Works in partnership with Avēsis personnel to improve system efficiency and collaborate on complex barriers that arise.
• Ability to operate in a fast-paced environment under tight deadlines.
• Ensures that the right systems, processes, and measurements are in place to assist with accurate clinical determinations are rendered.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)

Behavioral:

• Collegiality: building strong relationships on company-wide, approachable, and helpful, ability to mentor and support team growth.
• Initiative: readiness to lead or take action to achieve goals.
• Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing.
• Member-focused: going above and beyond to make our members feel seen, valued, and appreciated.
• Detail-oriented and thorough: managing and completing details of assignments without too much oversight.
• Flexible and responsive: managing new demands, changes, and situations.
• Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task.
• Integrity & responsibility: acting with a clear sense of ownership for actions, decisions and to keep information confidential when required.
• Collaborative: ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.

Minimum Qualifications:

• High School Diploma or Equivalent required.
• Minimum of 2 of years’ experience in dental benefit administration or related role.
• Dental Assistant or Dental Hygienist required.
• 1-2 years of experience reviewing dental x-rays, models, photos, and patient charts required. (X-Ray certification is highly desired).
• 1-3 years of experience managing multiple projects simultaneously while delivering results according to timelines required.
• 1-3 years of experience working with highly confidential information including PII, HIPAA Ability to maintain confidentiality required.
• 1-2 years of experience with utilizing windows-based computer programs, along with strong skills in navigating and utilizing MS Office suite applications such as Excel, Word, and PowerPoint required.
• 1-3 years of experience working in a fast-paced, rapidly changing environment required.
• As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 25 Mbps upload while hardwired and not on a VPN are sufficient.

Preferred Qualifications:

• X-Ray certification is highly preferred.
• Knowledge of Medicare, Medicaid, or commercial insurance
• Experience with HCPCS, CPT, CDT, and ICD-10 coding

We Offer

• Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
• Competitive compensation package.
• Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
• Life and disability insurance.
• A great 401(k) with company match.
• Tuition assistance, paid parental leave and backup family care.
• Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
• Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
• Employee Resource Groups that advocate for inclusion and diversity in all that we do.
• Social responsibility in all aspects of our work. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.

Equal Employment Opportunity
At Avēsis, We See You. We celebrate differences and are building a culture of inclusivity and diversity. We are proud to be an Equal Employment Opportunity employer that considers all qualified applicants and does not discriminate against any person based on ancestry, age, citizenship, color, creed, disability, familial status, gender, gender expression, gender identity, marital status, military or veteran status, national origin, race, religion, sexual orientation, or any other characteristic. At Avēsis, we believe that, to operate at the peak of excellence, our workforce needs to represent a rich mixture of diverse people, all focused on providing a world-class experience for our clients. We focus on recruiting, training and retaining those individuals that share similar goals. Come Dare to be Different at Avēsis, where We See You

Please refer the Job description for details