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Our Promise
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.
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
- Support office audits with Avēsis Provider Services Field Representatives, as needed.
- Available to support fraud and abuse investigations with the FWA department.
- Assistance with decisions regarding referrals and to whom referrals should be made.
- Other duties as assigned.
Qualifications:
Education:
- Dental Degree from an U.S. accredited Dental School.
- DDS or DMD; holder of an active, unrestricted Pennsylvania Dental License. Multi-state licensure preferred.
- Board Certification required for Specialty Dental Consultants
- Successful completion of an orthodontic specialty program from a U.S. accredited Dental School.
- Successful completion and currently active board certification in orthodontics from the American Board of Orthodontics.
Experience:
- A minimum of seven (7) years’ experience as a practicing Orthodontist.
Skills:
- Clear communication skills.
- Effective project management skills, especially time management.
- Word processing: Ability to learn claim processing systems; Familiarity with Microsoft Suite (Excel, Outlook, Word).
Knowledge:
- Requires a diverse level of knowledge and experience in dentistry.
- Experience in delivery of dental care; knowledge of government and commercial plan designs and administration a plus.
- Possessing the clinical background to render consistent opinions on emerging dental trends, utilization review, dental plan coverage, claims policy and standards of care a plus.
- Knowledgeable in the CDT code sets and descriptors is a plus.
- Membership in respective National Dental Specialty Association a plus.
Other:
- Completion of credentialing process following NCQA guidelines.
- Travel: TBD
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!
