Arkansas, Inc. is hiring: Dental Consultant in Sherwood

Job Summary: To review certain dental claims from a clinical perspective to determine benefits allowed based upon guidelines of the group contract.

Supervisory Responsibilities: None

Safety Sensitive: This position is classified as safety sensitive, meaning the duties require a high level of alertness, sound judgment, and accuracy, which directly impact the health and well-being of members. As such, this position may be subject to drug testing in accordance with company policy and applicable laws.

Primary Job Responsibilities:

• Reviews certain claims to include attachments (e.g. radiographs, periodontal charting, photos, narratives, and patient chart notes/progress notes) and make a determination to approve, deny, disallow, or allow alternate treatment based upon guidelines of the group contract.
• Administers claim review utilizing current processing policies/guidelines/standards, DeltaUSA processing policies, group contracts, provider agreements and state laws applicable to claims adjudication.
• Investigates, makes determinations, performs or coordinates adjustments on difficult provider claim appeals, confers with treating dentists on questionable treatment cases when indicated, and documents results.
• Keeps current on ADA CDT procedure codes, DeltaUSA processing policies, DDAR processing policies, policies of self-funded groups, and current dental techniques and procedures.
• Conducts medical necessity reviews, utilizing UM review criteria assigned cases.
• Reviews cases for potential quality of care concerns.
• Coordinates with Dental Review Specialists on issues relating to specific claim reviews when additional information is needed.
• Provides dental expertise and/or interpretation of dental policies, procedures codes and processing guidelines to internal and external contacts.
• Conduct peer-to-peer discussions with the treating provider to allow the treating provider a chance to discuss the UM determination in effort to alleviate the need for an appeal.
• Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

Minimum Qualifications:

• Will accept any suitable combination of education, training or experience.
• Position requires a current, unrestricted license to practice dentistry in Arkansas.
• Must have at least ten (10) years of clinical direct patient care experience in the practice of dentistry.
• Must be qualified to render a clinical opinion about dental conditions, procedures, and treatment.
• Must have knowledge of dental terminology.
• Must be able to read and interpret radiographs.
• Must be in good standing within the field of dentistry and the Arkansas State Board of Dental Examiners.
• Must be credentialed by Delta Dental of Arkansas.
• Must have good oral and written communication skills.
• Must have moderate computer skills.