Clinical Review Specialist Ortho I
Location: Milwaukee, Wisconsin US
Job Number: 788
The Ortho Clinical Review Specialist performs timely and accurate review and authorization of orthodontic services based on eligibility and contract requirements; while maintaining productivity and quality. The incumbent effectively works in multiple markets and produces departmental reports as needed.
PRIMARY JOB RESPONSIBILITIES:
- Review study models and pre-authorize orthodontic services based on Salzmann, HLD or Medical Necessity requirements for specific markets and eligibility, in accordance to contract language.
- Read and interpret x-rays, models, photos, and patient charts.
- Knowledge of reference materials and documentation that contain market nuances.
- Proficiently cross trained and able to meet production while working in multiple queues.
- Maintain quarterly IRR score of 90%.
- Ensure review of cases in Ortho CAD (electronic model submission).
- Communicate and work effectively with co-workers and Leads to coordinate workload.
- Respond to follow-ups daily.
- Provide customer service to provider, and members via the telephone regarding clinical questions.
- Represent DentaQuest in a professional manner at all times.
- Communicate to management ways to improve processes and productivity of company.
- Adhere to DentaQuest business processes.
- Other duties as assigned.
- High School Diploma or equivalent 2 years of orthodontic assisting experience or degree in dental field
- Knowledge of general computer software.
- Knowledge of telephone systems.
- Ability to read and interpret x-rays, dental models, photos, and/or patient charts.
- Ability to prioritize and organize multiple tasks.
- Ability to remain organized with multiple interruptions.
- Excellent verbal communication skills.
- Ability to work independently.
- Good interpersonal skills.
- Good PC Skills.
- Required to attend additional training as requested/deemed necessary.
PHYSICAL DEMANDS: Incumbent must be able to communicate effectively. Requires overall light physical effort (up to 25lbs.) Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer). Ability to travel or move about within and outside serviced facilities required. Incumbent works primarily in either a private or shared office environment.
At DentaQuest, we believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system - from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.
Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it.
To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and deliveringmeasurableoutcomes for the people we serve.
The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.
Job Number: 2570
Community / Marketing Title: Clinical Review Specialist Ortho I
Location_formattedLocationLong: Milwaukee, Wisconsin US