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Service Authorization Dentist - Remote

Date:  Aug 6, 2022
Location: 

Any city, AK, US, 99999

Req ID:  11641

Be part of a team that unleashes the power of leading-edge technologies to help improve the health and well-being of those most vulnerable in our country and communities. Working at HMS, a Gainwell Company carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. You’ll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance. We also have comprehensive leadership and technical development academies to help build your skills and capabilities.

Summary

HMS, a Gainwell Company

 

HMS is hiring a Dental Clinical Specialist who will be responsible for the Utilization Management and Utilization Review Programs and for ensuring the timely decision-making and adjudication of dental claims, referrals, and pre-authorizations across all business lines, including Commercial, Medicare Advantage, and Medicaid. They leverage their patient care background and experience to support the healthcare business process services team in implementing company products and solutions to help providers improve healthcare delivery. They will complete their work with a limited degree of supervision.

The HMS Dental Clinical Specialist should demonstrate technical proficiency in a range of processes or procedures acquired through job-related training and on-the-job experience. They may act as an informal resource for colleagues with less experience and complete a variety of atypical technical tasks. They will work within defined processes and procedures or methodologies and may help determine the appropriate approach for new assignments.

Your role in our mission

 

  • Recommends actions to resolve identified provider trends and treatment patterns.
  • Participates in Peer-to Peer calls to discuss utilization trends, quality issues, and trends in prospective and retrospective claims submissions.
  • Identifies potentially unnecessary services in relation to care delivery settings.
  • Examines dental charts for focused audits of aberrant utilization and care delivery patterns.
  • Provides occasional on-site chart review for the state provider network.
  • Uses clinical expertise to make appropriate dental interpretations and decisions, as required.
  • Develops and maintains subject matter expertise in dental benefit plans and applicable State Medicaid Programs.
  • As requested, contributes to required regulatory reporting.
  • Participates in Quality Improvement and Provider Credentialing Committees and provides input on appropriate resolution of member and/or provider grievances.
  • Collects and evaluates data from Grievance, Peer Review, Public Policy, and the Credentialing Sub-Committee on a quarterly basis.

What we’re looking for

 

  • DDS/DMD Degree required and active, unrestricted license or certification to practice dental or related health profession in the U.S. and must pass credentialing, with no probation or listed sanctions.
  • Five years' experience as a practicing dentist to include experience working with state Medicaid, Medicare, or Commercial Programs.
  • Knowledge of current dental terminology, practices, materials, and generally accepted standards, and knowledge of clinical dentistry procedure codes and generally accepted clinical and adjudication guidelines on medical necessity of proposed dental procedures.
  • Ability to examine and read dental radiographs and chart records.
  • In-depth knowledge of managed care delivery systems, reimbursement mechanisms, quality improvement initiatives, and cost reduction methods.

What you should expect in this role

 

Work-from-Home or Hybrid environment.

Work-from-home (WFH); or Hybrid model including in-office and WFH days to be defined. For positions assigned to WFH, reliable high-speed internet connectivity is required.  Employees working-from-home may be required to report to the office, at times, to support work efforts.

 

The pay range for this position is $160,700.00 - $200,900.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at HMS, a Gainwell Company. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

 

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with HMS, a Gainwell Company, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about HMS, A Gainwell Technologies Company at our company website and visit our Careers site for all available job role openings.

 

HMS, a Gainwell Company is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.

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