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Our Promise
Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.Job Description Summary
Avesis is seeking a Part Time Dentist (DDS) to assist with adjudications and support Dental Program Management efforts to build and maintain network relationships in California. Our chosen professional will effectively interact with control of fraud, waste, and abuse (FWA/SIU) activity under Compliance’s leadership and the Quality division within the company’s state sponsored dental programs along with other government and commercial plans.. This individual will also review Medicaid, Medicare Advantage, and commercial dental claims, reauthorizations, and appeals along with other inquires in accordance with dental policy and standard of dental practices within contractual benefits.

This role will also assist with:

Claim Review and Utilization Management

Pre-Auth Review

• Processes and/or adjudicates claims or treatment authorization requests that require professional review; reviews supporting documentation and adjudication by applying dental standards.
• Reviews Pre-treatment authorization services for determination of medical necessity within plan guidelines.
• Consultant will access queues on Avēsis HIPAA compliant platform for online adjudication.
• Consultant will regularly monitor queues for claims and prior authorizations in need of timely adjudication.
• Consultant must consistently meet California’s required turnaround times (TAT) specific to that state contract.
• Consultant will be aware of the need to confirm eligibility for provided services and limitations based on plan guidelines.

Post Service Reviews

• Reviews services requiring post-treatment review to determine compliance with plan and clinical guidelines.

Appeals

• Reviews appeals as directed by State Dental Director.
• Provider appeals committee attendance as requested by State Dental Director, or as needed.

Audits/FWA/SIU

• Consultant will review audit cases opened by compliance

Peer-To-Peer Reviews

• Performs peer-to-peer reviews by calling dental offices and dentists to discuss denials and their issues from claim submissions when required by the state or plan. On-site Reviews
• Educate dentists and related personnel in the process of evaluating the quality of care of a dental practice by performing an onsite review of dental records, procedures, and structural assessment.

Support Role

State Fair Hearings

• Support State Dental Director by reviewing scheduled Dental California Fair Hearing cases prior to the scheduled Fair Hearing Meeting, as directed by State Dental Director.
• Support State Dental Director by providing clinical review and justification at the Fair Hearing Meetings, as directed by State Dental Director.
• Assist relevant departments in coordinating any determination decisions made from the Fair Hearing Meetings, as directed by State Dental Director.

Support for UM and SIU/FWA

• Support the Dental Director in review of Utilization Management, such as authorization, appeals, and claim reviews.
• Assist in case reviews for clinical vendor oversight programs as well as clinical chart audit reviews.
• Review investigatory audits as directed by FWA/SIU/Compliance.
• Provide support in tracking and trending provider activity and providing alerts to Avēsis concerning unusual practice patterns or potential abuses.

General Support

• Support the Dental Director in Clinical and Quality programs and initiatives.
• Serve as a clinical advisor to Avēsis committees including but not limited to Quality Improvement Committee, Dental Medicaid Utilization Management Committee, Dental Advisory Committee, Provider Appeals Committee, and others.
• Provide support to the Dental Director for any state meetings or meetings with external advocacy groups or clients.

Clinical Calibration

• Assist with review of Policies and Procedures, guidelines, and clinical protocols relative to the Dental programs as directed by the State Dental Director
• Participate with monthly state meetings chaired by the State Dental Director to bring line of sight on potential obstacles with the pre-authorizations, post reviews and/or appeals.
• Participate with in-state Incidence Rate Ratio (IRR) chaired by the State Dental Director to assure continued adjudication calibration.

Interaction with Avēsis Provider Relations Field Staff

• Support office audits with Avēsis Provider Services Field Representatives, as needed.
• Available to support fraud and abuse investigations with the FWA department.
• Assistance with decisions regarding referrals and to whom referrals should be made.

Qualification Requirements:

• Dental Degree from an U.S. accredited Dental School.
• Seven (7) years’ experience as a practicing dentist or dental specialist.
• DDS or DMD; holder of an active, unrestricted California dental license.
• CADP Quality Assurance Certification
• Knowledgeable of current HIPAA, ADA, and DBC, requirements and perform job functions to meet these requirements.
• Experience in delivery of dental care; knowledge of government and commercial plan designs and administration a plus.
• Ability to communicate ideas clearly and professionally while addressing sensitive and confidential matters verbally, in writing, and via phone.
• Ability to self-direct, self-motivate, make independent decisions, and prioritize daily activity
• Ability to assess, problem solve, analyze, plan, and evaluate situations using critical thinking skills, reasoning and research.
• Word processing: Ability to learn claim processing systems; Familiarity with Microsoft Suite (Excel, Outlook, Word).
• Must be capable of collaborating with others in a team atmosphere. Ability to handle sensitive situations in a positive, professional manner
• Diverse level of knowledge and experience in dentistry.
• Posses clinical background to render consistent opinions on emerging dental trends, utilization review, dental plan coverage, claims policy and standards of care a plus.
• Knowledgeable in the CDT code sets and descriptors is a plus.
• AADC certification a plus.
• Completion of credentialing process following NCQA guidelines.
• Travel: TBD

We Offer

• 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. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.

Equal Employment Opportunity

At Avēsis, We See You.  We celebrate differences and are building a culture of inclusivity and diversity. We are proud to be an Equal Employment Opportunity employer that considers all qualified applicants and does not discriminate against any person based on ancestry, age, citizenship, color, creed, disability, familial status, gender, gender expression, gender identity, marital status, military or veteran status, national origin, race, religion, sexual orientation, or any other characteristic.  At Avēsis, we believe that, to operate at the peak of excellence, our workforce needs to represent a rich mixture of diverse people, all focused on providing a world-class experience for our clients.  We focus on recruiting, training and retaining those individuals that share similar goals.  Come Dare to be Different at Avēsis, where We See You!