Clinical Review Support Specialist

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.

At Sun Life, we're driven by our Purpose: helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful. When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives.

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.

About the role

The Clinical Review Specialist I provides timely and accurate review and authorization of dental services based on eligibility and contract requirements.

Responsibilities

• Successful completion of the Clinical Review Specialist training program
• Read, interpret and analyze x-rays, models and requests for major dental services based on medical necessity, client coverage, provider participation and member eligibility, in accordance with contract language
• Resolve claim and prior authorization suspends that require UM Review
• Consistently meet productivity requirements
• Maintain audit score of 95% or greater
• Pass the IRR quarterly
• Communicate and work effectively with co-workers and Leads to coordinate workload to ensure all work is completed daily
• Knowledge of reference materials and documentation that contain market nuances
• Respond to follow-ups
• Provide customer service via the telephone to providers regarding clinical issues
• Other duties as assigned
• Represent DentaQuest in a professional manner at all times
• Adhere to DentaQuest business processes
• Perform peer clinical reviews

Requirements

• High School Diploma or equivalent
• 1 year dental assisting experience
• Ability to read and interpret x-rays, dental models, photos, and/or patient charts
• Good interpersonal skills
• Ability to work independently
• Excellent oral and written communication skills
• Efficient PC skills (Word, Excel, Outlook)
• Ability to prioritize and organize multiple tasks
• Ability to remain organized with multiple interruptions
• Knowledge of telephone systems
• Ability to work in excess of 40 hours in a week
• Required to attend additional training as required/deemed necessary

Previous dental insurance experience a plus.

Pay

The salary range for this role is $38,200 - $51,600. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business.

Benefits

• Generous vacation and sick time
• Market-leading paid family, parental and adoption leave
• Medical coverage
• Company paid life and AD&D insurance
• Disability programs
• Partially paid sabbatical program
• 401(k) employer match
• Stock purchase options
• Employer-funded retirement account

We’re proud to be recognized in our communities as a top employer. Proudly Great Place to Work® Certified in Canada and the U.S., we’ve also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row.