DentaQuest, Inc. Utilization Management Clinical Auditor in United States
Utilization Management Clinical AuditorLocation:Connecticut, United States
Position Title:Quality Assurance Clinical Auditor
The primary objective of this position is to perform routine and focus Utilization Management audits electronically to identify inaccurate clinical benefit determinations.
PRIMARY JOB RESPONSIBILITIES:
Perform individual, departmental and specialized audits within the utilization management department.
Assess accuracy and consistency of clinical benefit determination for each Benefit Examiner.
Ability to audit consistency of clinical and administrative decisions based on clinical guidelines and proprietary algorithms.
Review diagnostic materials, such as dental models, x-rays, periodontal charting, to determine appropriateness of benefit determination.
Identify prevalent trends and recommend immediate resolution techniques to management.
Work with Lead Benefit Examiner, and Clinical Trainer to develop training sessions.
Maintain high level of confidentiality relating to audit reviews and audit findings.
Collaborate with Utilization Management staff and leadership team on the use of established business processes, procedures and related tools.
Work with Utilization Management leadership team to identify, develop, and implement business processes and tools used by staff to improve clinical benefit determination accuracy results.
Work with benefit examiners to resolve difficult or complex claims, and recommend related training opportunities that will improve clinical benefit determination results.
Work with benefit examiners and leadership team to develop and implement new or revised business processes as required by the enterprise wide project office or compliance team (regulatory changes).
Adhere to Interrater Reliability principles to ensure the audit results generated meet the accepted criteria by quantitatively defining the degree of agreement between two or more auditors.
Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach.
Develop and coordinate the implementation of systems, procedures and forms to improve data collection.
Assist in the development of action plans to address quality deficiencies.
Other duties as needed or required.
Produce weekly, monthly, quarterly and annual management and operations focused reports.
Assist in developing and maintaining dashboard to report Corporate and Client Quality results.
Other duties as needed or required.
Two to four year College Degree preferred. High School diploma/GED Required.
A combination of 2 or more years of Claims Processing or Utilization Review experience in health care industry, preferably in an auditing role.
2 or more years of dental assisting experience or degree in dental field.
Ability to analyze, interpret and apply business and operational policies and procedures for prompt and accurate clinical benefit determinations.
Ability to read and interpret dental models, x-rays, photos, narratives, and or patient charts.
A thorough understanding of dependents, relationship types and eligibility guidelines to ensure consistency in validation of plan participation.
Proven logic and reasoning skills that apply methods of consistency, validity, soundness and completeness.
Ability to make sound decisions.
Ability to analyze and solve problems
Strong interpersonal, written and oral communication skills.
In depth knowledge of Windward a plus.
Strong computer skills. Intermediate to Advanced knowledge of Microsoft Excel, Access and Word required.
Ability to work overtime as needed or required.
Position is based on-site at either our Mequon, Wisconsin or Boston, Massachusetts location.
Requires the effective use of all office equipment including, but not limited to, telephone, computers, printers, and fax machines.
Ability to sit in front of computer terminal for extended periods of time.
The Quality Assurance area is located in a wheelchair accessible building. The office environment is active with high voice levels and interruptions that may challenge hearing and concentration.
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria necessary to successfully perform this position.
* In accordance with DentaQuest’s Compliance Plan, employee must conduct DQ business in accordance with applicable laws, regulations, professional standards and ethical standards and report potential compliance or ethical issues to manager or DQ’s Compliance Officer. *
DentaQuest’s Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please see Human Resources for additional information regarding this Program.
Community / Marketing Title:Utilization Management Clinical Auditor
We believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system – from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.
Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it.
To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and delivering measurable outcomes for the people we serve.
The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.
Location_formattedLocationLong:Remote, Connecticut US
CountryEEOText_Description:In accordance with our Compliance Plan, employees must conduct business in accordance with applicable laws, regulations, professional standards and ethical standards and report potential compliance or ethical issues to manager or Compliance Officer. Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please see Human Resources for additional information regarding this Program.
Equal Employment Opportunity Statement: We are committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, or sexual orientation.