Dental Consultant: Oral Surgeon- California (Part-time)

Summary

Gainwell Technologies Dental Consultants apply clinical expertise to review, approve, and/or deny dental treatment authorization requests and claims in accordance with CA Department of Health Care Services (DHCS) Medi-Cal Dental policies.

Your role in our mission

• Review dental records to determine medical necessity of oral maxillofacial surgery (OMS) services within professionally recognized standards of care.
• Manually adjudicate Treatment Authorization Requests (TARs), Notices of Authorization (NOAs) and Claim Inquiry Forms (CIFs) utilizing standards and procedures set forth by the CA Department of Health Care Services (DHCS) to ensure adherence to Medi-Cal Dental policies and procedures.
• Works within a team of dental consultants, including other OMS, sharing a proportional workload of prior authorization and/or claims processing that have been determined to need professional expertise of an experienced OMS. These claims have been referred from other members of the Claims Processing team, usually involving special needs patients, and good communication skills are necessary for continuity within the business operations.
• When needed, OMS dental consultants assist with training and orientation of new dental consultants, providing guidance and mentoring, such as job coaching and peer interaction including assistance with complex cases or claims.
• Assists other departments, when requested: a) Claims Processing and Operations, b) Provider and Member Services, c) Grievances/Appeals, d) HR/Onboarding/Interviews, e) Quality Management, f) Peer review, and g) Providing findings to the claims processing team and/or adjudication of claims related to OMS cases.

What we're looking for

• Active and unrestricted license to practice dentistry in the State of California, in good standing and free of any suspensions, restrictions, or sanctions from federal, state, or local regulatory authorities.
• Board Certified Oral Surgeon required.
• A minimum of ten (10) years of prior hands-on, clinical experience as an OMS Specialist delivering dental services. The candidate must be a recognized Specialist in OMS and meet all requirements and training set forth by the Board of Dental Examiners in California.
• Familiarity with the Medi-Cal Dental Program is preferred and should be discussed during the screening process.
• Expertise and knowledge of Medi-Cal Dental criteria and program requirements.
• Candidates must possess intermediate-level computer proficiency and be comfortable using standard business applications and systems.

What you should expect in this role

• Candidates must reside and work in California. Working from or performing work in any other state is not permitted.
• Remote within the state of California, with On-Site (Roseville, CA) as needed. In-office requirements are subject to change based on DHCS requirements.
• This is a part-time role requiring an 8-hour workday. Employees are expected to dedicate their full attention to this position during scheduled work hours. Holding another job during the same working hours is not permitted. Work hours must be completed between 7:00 AM and 5:00 PM.
• Candidates must be able to remain seated and work at a computer for up to 8 hours per day.
• PTO requests are reviewed and approved based on business needs.
• Candidate must complete a Conflict of Interest Disclosure and remain compliant with all company conflict-of-interest policies.