Come Smile with Us!
Are you a licensed dental hygienist interested in a part-time role (30 hours/week) seeking to use your expertise outside of a clinical setting? Delta Dental of Iowa is inviting candidates for a new part-time Utilization Management Specialist. You will responsible for pre and post service review, decision making of complex claims, dental office adherence to claim processing policies, and working with leadership to review aberrant treatment profiles according to department guidelines. You will monitor the daily workload of claims, adjustments, and inquiries to ensure timely processing. You will also conduct monthly quality review of processed claims. At 30 hours per week, this is a benefit-eligible position.
Delta Dental of Iowa provides dental and vision insurance to more than 1.5 million Iowans. As a not-for-profit insurance company, our mission is to improve the health and smiles of the people we serve. We give back to Iowa communities by supporting and funding health and wellness initiatives that make a measurable difference in the overall health of underserved Iowans. Come see why we are passionate about "Bringing Smiles" to our customers. Our team enjoys competitive pay and benefits, an awesome "One Team" approach, and a company culture that fosters "Exceptional Quality Service" and "Leadership at All Levels." Love where you work!
Essential Functions and Principal Accountabilities:
- Analyze supporting documentation to make decisions regarding pre and post service delivery.
- - Request and utilize appropriate radiographs for the specific review situation.
- - Evaluate appropriate clinical measurements for the reported code in periodontal charting.
- - Interpret detailed narratives and treatment notes, specific to the treatment provided.
- - Ensure final claim disposition, including adjustments when necessary, is made within established guidelines of the contract terms.
- - Prepare cases and work with the Director, Operations Man, Dental Director, and/or the Dental Consultants when necessary to review complex cases.
- Conduct quality assurance of processed claims for all department reviewers and processors.
- Communicate with dental offices for effective issue resolution and explanation of clinical or administrative policy as required.
- Participate in meetings and discussions as needed for clinical criteria.
- Lead and/or participate in special projects on time and with high quality. May include assisting with system requirements, perform testing, documentation, training. Assist the call center staff by answering complex claims processing questions from stakeholders. Train on processing policies and CDT updates.
- Provide courteous assistance to customer inquiries by phone, system inquiries, email/letter or in person.
- Work with new staff to ensure training needs are met.
- Represent Delta Dental in a highly energized, positive, professional and effective manner at all times, including, but not limited to;
- - Establish and maintain a positive team working relationship with all co-workers and internal and external stakeholders.
- - Recommend and actively participate in implementing process improvements
- - Adhere to processing standards related to quality, documentation and turnaround time.
- - Comply with the policy and procedures of Delta Dental at all times, including department standards and guidelines as applicable.
- Assist other areas of Delta Dental to meet corporate goals.
- Maintain strict confidentiality; adherence to all HIPAA laws is required at all times.
- Perform other duties as assigned.
- Licensed Dental Hygienist with a minimum of 3-5 years’ experience in a dental office or insurance company with specific knowledge of CDT coding and nomenclature. Benefit plan contract language and claims administration computer system experience preferred.
- Demonstrated knowledge of claims processing and dental treatment procedures, including the ability to read clinical records including: radiographs, periodontal charting and treatment notes. Knowledge of alternative dental treatment techniques preferred.
- Demonstrated ability to identify, research, and resolve issues by making sound decisions in accordance with policies and procedures.
- Excellent written and verbal communication skills.
- Ability to interact with internal and external stakeholders in an effective and positive manner.
- Demonstrated competency in computer skills, including Microsoft Excel and Word, as well as other software as required.
- Demonstrated ability to prioritize, organize and function effectively with multiple tasks/assignments.
- Ability to analyze information and make independent decisions.
- Ability to work independently or as part of a team to complete assigned tasks and achieve goals.
- Competency in basic math ability.
- Ability to travel when necessary.
Delta Dental of Iowa is an Affirmative Action and Equal Opportunity Employer committed to providing equal employment opportunity for all persons without unlawful regard of race, color, religion, sex, sexual orientation, gender identity, age, national origin, individuals with disabilities, protected veteran status, or any other legally protected basis.