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Avesis is seeking a Part Time Dentist / Orthodontist (DDS) in the state of Florida to assist in an adjudication role in reviewing Medicaid, CHIP, Medicare Advantage, and commercial dental claims and preauthorization’s. This role includes supporting Dental Program Management efforts to build and maintain network relationships and effectively interact with control of fraud, waste, and abuse (FWA) activity under Compliance’s leadership and the Quality division within the company’s state sponsored dental programs and other government and commercial plans.

Essential Job Functions and Responsibilities:

Claim Review and Utilization Management

• Pre-Auth Review
  • Processes and/or adjudicates claims or treatment authorization requests that require professional review; reviews supporting documentation and adjudication by applying dental standards.
  • Reviews Pre-treatment authorization services for determination of medical necessity within plan guidelines.
  • Consultant will access queues on Avēsis HIPAA compliant platform for online adjudication.
  • Consultant will regularly monitor queues for claims and prior authorizations in need of timely 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 Reviews
  • Reviews services requiring post-treatment review to determine compliance with plan and clinical guidelines.
• Appeals
  • Reviews 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/FWA
  • Consultant will review audit cases opened by compliance

• Peer-to-Peer through Quality Department
  • Performs peer-to-peer reviews by calling dental offices and dentists to discuss denials and their issues from claim submissions when required by the state or plan.

Supportive Role

• State Fair Hearings
  • Support 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 decisions made from the Fair Hearing Meetings, as directed by State Dental Directors or Associate National Dental Director.

• Support for UM and FWA
  • Support 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 oversight programs as well as clinical chart audit reviews.
  • Review investigatory audits as directed by FWA/Compliance.
  • Provide support in tracking and trending provider activity and providing alerts to Avēsis concerning unusual practice patterns or potential abuses.

• General Support
  • Support the Dental Director in Clinical and Quality programs and initiatives.
  • Serve as a clinical advisor to Avēsis committees including but not limited to Quality Improvement Committee, Dental Medicaid Utilization Management Committee, Dental Advisory Committee, Provider Appeals Committee, and others.
  • Provide support to the Dental Director for any state meetings or meetings with external advocacy groups or clients.

• Clinical Calibration
  • Assist with the review of Policies and Procedures, guidelines, and clinical protocols, relative to the Dental programs, at least annually.
  • Participate, when 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 pre-authorizations, post reviews and/or appeals.
  • Participate with in-state Incidence Rate Ratio (IRR) chaired by the State Dental Director to assure continued adjudication calibration.

• Interaction with Avēsis Provider Relations Field Staff
  • Suppo