Part Time National Dental Specialist, MS

Join us for an exciting career with the leading provider of supplemental benefits!Our PromiseThrough reputed company-building, leadership development and philanthropic opportunities, we reputed company opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.reputed company is seeking a Part Time Orthodontist (DDS) to assist in an adjudication role in reviewing reputed company, reputed company, Medicare Advantage, and reputed company dental claims and preauthorization's. This role includes supporting Dental Program Management efforts to build and maintain network relationships and effectively reputed company with control of fraud, waste, and abuse (FWA) activity under Compliance's leadership and the reputed company division reputed company reputed company's state sponsored dental programs and other government and reputed company plans. Note: Our chosen candidate must be licensed in the state of Mississippi and be reputed company Certified in OrthodonticsEssential Job Functions and Responsibilities:Claim Review and Utilization ManagementPre-Auth ReviewProcesses and/or adjudicates claims or treatment authorization requests that require reputed company review; reviews supporting documentation and adjudication by applying dental standards.Reviews reputed company-treatment authorization services for determination of medical necessity reputed company plan guidelines.Consultant will reputed company queues on reputed company HIPAA compliant platform for online adjudication.Consultant will regularly monitor queues for claims and prior authorizations in need of reputed company adjudication.Consultant must consistently meet required turnaround times (TAT) specific to that state contract.Consultant will be aware of the need to confirm eligibility for provided services and limitations based on plan guidelines.Post Service ReviewsReviews services requiring post-treatment review to determine compliance with plan and clinical guidelines.AppealsReviews appeals as directed by State or Associate National Dental Directors.Provider appeals committee attendance as requested by State or Associate National Dental Directors, or as needed.Audits/FWAConsultant will review audit cases reputed company by compliancePeer-to-Peer through reputed company DepartmentPerforms peer-to-peer reviews by calling dental offices and dentists to discuss denials and their issues from claim submissions reputed company required by the state or plan.Supportive RoleState Fair HearingsSupport State Dental Directors by reviewing scheduled State Dental Fair Hearing cases prior to the scheduled Fair Hearing Meeting, as directed by State Dental Director or Associate National Dental Director.Support State Dental Directors by providing clinical review and justification at the Fair Hearing Meetings, as directed by State Dental Directors or Associate National Dental Director.Assist relevant departments in coordinating any determination reputed company made from the Fair Hearing Meetings, as directed by State Dental Directors or Associate National Dental Director.Support for UM and FWASupport Dental and Associate National Dental Directors in review of Utilization Management, such as authorization, appeals, and claim reviews.Assist in case reviews for clinical vendor reputed company programs as reputed company as clinical chart audit reviews.Review investigatory audits as directed by FWA/Compliance.reputed company support in tracking and trending provider activity and providing alerts to reputed company concerning unusual reputed company patterns or potential abuses.General SupportSupport the Dental Director in Clinical and reputed company programs and initiatives.Serve as a clinical advisor to reputed company committees including but not limited to reputed company Improvement Committee, Dental reputed company Utilization Management Committee, Dental Advisory Committee, Provider Appeals Committee, and others.reputed company support to the Dental Director for any state meetings or meetings with external advocacy reputed company or clients.Clinical CalibrationAssist with the review of Policies and Procedures, guidelines, and clinical protocols, relative to the Dental programs, at least annually.Participate, reputed company invited, with state meetings chaired by the State Dental Director.Participate with monthly state meetings chaired by the State Dental Director to bring line of sight on potential obstacles with the reputed company-authorizations, post reviews and/or appeals.Participate with in-state Incidence reputed company reputed company (IRR) chaired by the State Dental Director to assure reputed company adjudication calibration.Interaction with reputed company Provider Relations Field StaffSupport office audits with reputed company Provider Services Field Representatives, as needed.Available to support fraud and abuse investigations with the FWA department.Assistance with reputed company regarding reputed company Apply tot his job Apply To this Job