Dental Hygenist Clinical Utilization Reviewer - Remote

CNSI and Kepro are now Acentra Health! Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the company’s mission, actively engage in problem-solving, and take ownership of your work daily. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra seeks a Dental Hygienist Reviewer to join our growing team.

Summary Description

The Dental Clinical Specialist is responsible for the Utilization Management and Utilization Reviews to ensure the timely decision-making and adjudication of dental claims, referrals, and pre-authorizations. Prior authorization and post payment reviews leverage patient care and treatment planning experience to support the healthcare business process services team. Our client may also request evaluations of dental health policy and preventative treatment plans. The Dental Clinical Specialist will complete their work with a limited degree of supervision.

Responsibilities include, but are not limited to

• Review first-level Prior Authorization (PA) requests related to handicapping malocclusions, general dentistry requests, and treatment plan evaluations.
• Acentra Health is responsible for all levels of review:
• First-level reviews will be completed by a professional with expertise in this area.
• If a secondary review is necessary, such as denials, appeals, and fair hearings, the Dental Clinical Specialist would ensure that cases are prepared, completed within timeframes, by our peer to peer licensed dental provider.
• Ensure compliance with a turnaround time for all first-level reviews.
• Utilization Management data will be reported each month covering:
• Number of reviews
• Percent approved
• Percent denied
• Percent appealed or went to a fair hearing
• Percent upheld at appeal or fair hearing
• Percent overturned and reason
• Percent returned for additional information, trends or issues
• Develop and maintain good relationships with contracted providers.

• Consistently review and report trends, and opportunities for program improvement.
• Perform other tasks as assigned or necessary.

Requirements

• Dental Hygienist with at least three years of clinical experience.
• Experience with tools related to handicapping …