Sr. Clinical Dental Consultant, DentaQuest (Louisianna)

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

Job Description:

Location: Must live in Louisianna

At Sun Life, we look for optimistic people who want to make life brighter for our Clients. We understand the value of diverse cultures, perspectives, and identities, and want you to bring your full and authentic self to work. Every day, you’ll be empowered and challenged by working with dynamic colleagues to find new and innovative ways to make Sun Life the best benefits company in America. 

The opportunity: 
The Sr. Clinical Dental Consultant reviews claims based on medical necessity, in accordance with market contracts, evaluate appeals, counsel providers, identify providers with aberrant utilization patterns, provide clinical aid for provider outreach, and act as a clinical SME (or liaison) for internal entities.

How you will contribute:

• Authorize or deny claims based on medical necessity and eligibility, in accordance to contract language after clinical review enters claim status into the system.
• Evaluate appeals and identify if proper documentation has been obtained to deny claim. Make further recommendations, request additional information, review charts, and make revised or reiterate claim decision.
• Reviews authorization requests for anesthesia and rendering judgement on medical necessity.
• Review and render conclusions on all orthodontic claims for handicapping malocclusions specific to each Market contract.
• Communicate claim review outcome to participating Dentists, plan members, and Health Plans.
• Facilitate and give Provider orientations.
• Communicate to management ways to improve processes and productivity of company.
• Develop a full comprehension of the administration of the dental program, including, but not limited to: benefit and authorization requirements for Plans and/or States, claims payment and the denial process, and a business understanding of ASO and Risk relationships.
• Develop knowledge and understanding of state and federal dental regulations, and proactively alert staff of changes that are taking place.
• Provide guidance and education in the provider community on the dental program; provide recommendations in managing the dental program efficiently and effectively.
• Represent the company in a professional manner for the market, including meetings associated with the provider community.
• Proactively seek out opportunities to speak on the benefits of Medicaid and Medicare dental programs.
• Identify community opportunities for the company to participate within, including, but not limited to: health fairs, dental screenings, back to school programs, etc.
• Develop an understanding of the oral health wellness and outreach programs offered, working closely with Dental Consultants and staff.
• Review dental cases to represent the company at fair hearings, as needed.
• Establish relationships with dental associations and key stakeholders in the surrounding region, helping to solidify new business in other states.
• Adhere to business processes.
• Recruit qualified providers for the network.
• Other duties as assigned.

What you will bring with you:

• Graduate of an accredited Dental School (D.D.S. or D.M.D).
• MUST be licensed in Louisianna.
• Orthodontic experience a plus
• Maintain an unrestricted dental license.
• Knowledge of general dentistry.
• Efficient PC skills.
• Ability to use analytical/presentation tools such as Excel and PowerPoint.
• Organizational and time management skills.
• Ability to work with a team and independently to complete assigned tasks without supervision.
• Ability to make independent determinations on all types of dental claims.
• Excellent written and verbal communication skills.
• Ability to distinguish between multiple market benefits.
• Ability to prioritize and organize multi