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Utilization Management Reviewer (Dental)

Argus Dental & Vision, Inc.

Location: Tampa, FL 33607
Type: Non-Remote
Posted on: October 14, 2020
This job is no longer available from the source.
Utilization Management Reviewer (Dental)
Argus Dental & Vision, Inc.
25 reviews
-
Tampa, FL 33607
Argus Dental & Vision, Inc.
25 reviews
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Job Summary
Primary role is providing high-level analysis of benefit data, clinical data and applying it to operational activities of Argus providers. The UM Reviewer is responsible for managing all provider requests for pre-determinations and pre-authorizations.
Summary of Essential Job Functions
• Reviews requests for pre-determinations and pre-certification for coverage and
• compliance with Argus Dental and Vision, Inc. Clinical Guidelines and Provider
• Manual.
• Evaluates requests for completeness and communicate with providers or with
• Support Specialist to obtain additional information if necessary.
• Reviews requests to make sure the requested services fall within the individual
• member’s benefit coverage and limitations.
• Reviews requests to make sure the requested services fall within the Clinical
• Guidelines/provider manual, and only approves services for which there is specific
• criteria.
• Consults with medical director regarding cases that fall outside the parameters in the
• clinical guidelines/provider manual.
• Communicates positive determinations/authorizations to requesting providers. Communicates negative determinations/authorizations to health plan staff according
• to denial protocols required by health plan/CMS.
• Works with health plan staff to coordinate services not covered under our contracts
• with the health plans that may need specialty oversight even though the health plan
• is responsible for reimbursement.
• Coordinates out of network referrals which may include initial contact, fee
• negotiation, and provider education. Consults and collaborates with provider
• network management team to arrange single case agreements where necessary.
• Coordinates second opinions at member’s request.
• Ensure compliance with local, state and federal laws, Medicare regulations and Argus’ policies and procedures.
• Displays a willingness to support the policies and procedures and uses appropriate channels for change of such policies.
• Interact professionally with other employees, providers, members.
• Work independently while understanding the need to communicate and coordinate work efforts with other staff and organizations.
• Perform job responsibilities in compliance with all Argus Dental & Vision Operating Policies and procedures.
• Complete required annual education courses within the expected timeframes.
• Be cognizant of and adhere to principles of Patient and Provider Rights and Responsibilities as outlined in Argus materials and policy documents.
Required Knowledge, Skills and Abilities
• Microsoft Office Suite Tools
• Ability to learn customized software systems
• Ability to facilitate relationships with health plan partners, to coordinate member care.
• Ability to facilitate relationships with Argus providers, and along with Provider Network Management team, communicate, educate and assist providers in efficiently processing the necessary paperwork to obtain approval for medically necessary
Required Experience
• Minimum 2 years of chair-side dental assistant experience in a dental office.
• Expanded function dental assistant certification.
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.