Part Time Dental Consultant, Kentucky

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Avesis is seeking a Part Time Dentist (DDS) to assist with adjudications and support in reviewing CHIP, Medicaid, Medicare Advantage, and commercial dental claims and preauthorization’s (all contracts Avesis manage). The role includes supporting Dental Program Management efforts to build and maintain network relationships in Kentucky, and effectively interact with control of fraud, waste, and abuse (FWA) activity under Compliance’s leadership and the Quality division within the company’s state sponsored dental programs and other government and commercial plans.

*NOTE: This is a 20-29 hour, work from home/remote role. Per our government contract, candidates must both reside and work in the State of Kentucky.

Essential Job Functions and Responsibilities:

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 Kentucky’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
  • Consultant will review audit cases opened by compliance.

• Peer-to-Peer through Quality Department
  • 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.

Supportive Role

• State Fair Hearings
  • Support State Dental Director by reviewing scheduled Dental Kentucky’s 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 FWA
  • …