Dental Reviewer

CareSource - Atlanta, GA3.7

Role and Responsibility:
Support staff by providing training, clinical consultation, and clinical case review for members
Participate in peer-to-peer discussions
Provide provider education, training, data sharing, performance evaluations and orientation to the plan
Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns
Participate in development of policies and procedures
Provide cross-coverage for other Dental Directors and/or markets, as needed
Provide prior authorization medical reviews, consultation and clinical review services
Conduct clinical reviews for designated CareSource members
Clinical Appeals
Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs
Perform any other job related instructions, as requested

Education / Experience:
A DDS or DMD degree from a dental school accredited by the American Dental Association Commission on Dental Accreditation is required
Successful completion of a residency training program, preferably in primary care is required
Minimum of five (5) years of clinical practice experience is required
Managed care medical review/dental director experience is preferred
Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred

Required Competencies / Knowledge / Skills:
Knowledge of current dental terminology, practices
Basic Microsoft Word skills
Excellent communication skills, both written and oral
Ability to work well independently and within a team environment
Ability to create strong relationships with Providers and Members
High ethical standards
Attention to detail
Critical listening and systematic thinking skills
Ability to maintain confidentiality and act in the company’s best interest
Ability to act with diplomacy and sensitivity to cultural diversity
Decision making/problem solving skills
Conflict resolution skills
Strong sense of mission and commitment of time, effort and resources to the betterment of the communities served

Licensure / Certification:
Current, unrestricted license to practice dentistry in state of practice as necessary to meet regulatory requirements is required

Working Conditions:
General office environment; required to use general office equipment
May be required to work evenings/weekends
May be required to travel to fulfill duties of position