Utilization Management Clinical Dental Processor

Our Promise: Through skill-building, leadership development, and philanthropic opportunities, we provide ways to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.

About the role

As a Utilization Management Clinical Dental Processor, you will leverage your dental clinical expertise to review dental x-rays and documentation, assessing medical necessity for prior authorizations. You will perform initial reviews of medical necessity cases, ensuring they comply with member eligibility and the covered services outlined in each client contract.

The UM (Utilization Management) Department supports our clients and company by utilizing clinical criteria to approve or deny a service based on the authorization. The UM Clinical Dental Processor plays a crucial role in ensuring that healthcare services provided to members are appropriate, efficient, and effective by utilizing clinical criteria and evidence-based guidelines to evaluate the necessity and appropriateness of treatments.

You will apply national clinical criteria, maintain up-to-date knowledge of relevant laws, regulations, and organizational policies, and use clinical judgment in your evaluations. To meet client standards, you will complete 13 to 18 cases per hour. Additionally, you will complete clinical scripts, review patient histories, and import supporting documentation into our internal system.

Work hours will be determined by your manager and may vary based on location, department needs, and workflow. Mandatory overtime may be required during peak seasons.

Responsibilities

• Conduct reviews of prior authorizations by providers, determining cases of recommended treatment in accordance with Avesis UM procedural guidelines or referring the case to the Clinical Director or consultant for professional review of clinical denials.
• Ensure the right systems, processes, and measurements are in place to assist with accurate clinical determinations.
• Understand and uphold Avesis’ policies and obligations relative to the UM reviews required by each client contract.
• Document approval decisions for treatment in accordance with prescribed UM department procedural guidance and forward applicable files to the client health plan as required by each contract.
• Provide recommendations on department policies, objectives, and initiatives; evaluate and suggest changes to optimize processes and efficiencies.
• Work in partnership with Avēsis personnel to improve system efficiency and collaborate on complex barriers that arise.
• Maintain a daily level of productivity in accordance with departmental requirements for production and quality standards.
• Maintain effective intradepartmental communications through sharing plans, general company news, and other information; actively participate in routine departmental meetings.
• Perform other duties as assigned.

Core Competencies

• Maintain strict confidentiality of information related to Avēsis and its customers, following our information security policies. This obligation continues even after employment ends, including secure handling of data and access management.
• Be self-motivated and highly organized with the ability to work autonomously without direct supervision.
• Convey information and engage an audience in a professional setting.
• Operate in a fast-paced environment under tight deadlines and deliver high-quality work consistently.
• Use virtual platforms like Teams and Microsoft Outlook for collaboration; participate in regular monthly check-ins and bi-weekly department touch bases for market updates and team alignment.

Behavioral Competencies

• Collegiality: Build strong relationships company-wide; be approachable and helpful; mentor and support team growth.
• Initiative: Readiness to lead or take action to achieve goals.
• Communicative: Ability to relay issues, concepts, and ideas to others easily, both orally and in writing.
• Member-focused: Go above and beyond to make our members feel seen, valued, and appreciated.
• Detail-oriented and thorough: Manage and complete details of assignments without too much oversight.
• Flexible and responsive: Manage new demands, changes, and situations.
• Critical Thinking: Effectively troubleshoot complex issues, problem-solve, and multi-task.
• Integrity & responsibility: Act with a clear sense of ownership for actions and decisions; keep information confidential when required.
• Collaborative: Represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.

Requirements

• High School Diploma or equivalent required.
• 2+ years of either Dental Assistant or Dental Hygienist experience required.
• Dental Assistant certificate or 2 years of chair-side assisting required.
• 2 years of experience reviewing dental x-rays, models, photos, and patient charts required.
• Proficiency with Microsoft Office and other Windows-based applications.
• Strong reading, writing, and professional communication skills.
• Ability to manage multiple tasks and prioritize work.
• Adaptability to handle multiple and changing priorities.
• Effective time management and organizational skills.
• Access to reliable internet connection (25 MBPS upload/50 MBPS download speed) and an appropriate workspace are essential for success in this remote role.

Preferred Qualifications

• X-Ray certification highly desired.
• Knowledge of Medicare, Medicaid, or commercial insurance.
• Experience with HCPCS, CPT, CDT, and ICD-10 coding.

Pay

At Avēsis, we strive to design equitable and competitive compensation programs. Base pay within the range is ultimately determined by a candidate's skills, expertise, or experience. In the United States, we have three geographic pay zones. For this role, our current pay ranges for new hires in each zone are:

• Zone A: $18.33-$30.55
• Zone B: $19.97-$33.29
• Zone C: $21.50-$35.84

FLSA Status: Hourly/Non-Exempt. This role may also be eligible for benefits, bonuses, and commission. Please visit Avesis Pay Zones for more information on which locations are included in each of our geographic pay zones. However, please confirm the zone for your specific location with your recruiter.

Benefits

• 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, including volunteering within local communities, creating educational alliances with colleges, and driving sustainability initiatives.