Provideoperational support and basic investigative services to the Utilization Review (UR)Clinical Team. Review claims identifiedusing a Tableau-based data analytics tool to verify quality completion ofservices as billed and appropriate claim payment within contract terms. Use data analytics tool and claim reviewfindings to identify utilization and quality trends, including both codes potentially overutilized and preventiveservice codes potentially underutilized.
* Querya Tableau-based data analytics tool to identify potential claims forUtilization Review and provide trend reporting from the data analytics tool.
* Reviewidentified claims to verify quality completion of services as billed and appropriateclaim payment within contract terms. Record findings and create an Excel database that can be used to createreports identifying utilization and quality trends for review with ClinicalLeadership Team.
* Assist in developing programs that support the oral healthbetterment of members based on underutilization data for preventive services.
* Assistin making recommendation to pre-payment review processes for specificprovider/offices/DSO and/or CDT codes based on overutilization and qualitymeasure data.
* Referto DDS Utilization Review team member(s) any \"DDS level\" clinical claims andrelevant documentation for DDS clinical review and add findings to database.
* Internal UR Efficiency-using Data Analytics tool, review claimsand request additional information from offices/providers as needed for reviewpurposes.
* Efficient UR Controls- Identify claims for utilizationreview DDS only post-payment review, request additional information fromoffices/providers as needed for review purposes, and provide to DDS for review.
* Compliance-Record all review data, create reports, andparticipate in regular meetings to discuss findings and recommendations withClinical Leadership Team.
* Assistwith special projects
This position reports to the Senior Dental Director of UtilizationManagement. Who in turn reports to the Commercial and Government Markets ChiefDental Officer.
List essential knowledge,skills and abilities required to perform effectively for the role,specifically. For a list of functionalskills refer to the Guardian Interview Guide.
* Understandingrules and definitions of ADA CDT coding
* Experiencedealing with dental or medical offices
* Proficientwith all programs within Microsoft Office and use of internet resources
* Abilityto use software to extract and evaluate data
* Outstandingwritten and verbal communication skills
* Self-motivatedwith the ability to thrive in a non-structured environment
* Respectfor Diversity
* Effectivelycollaborates with other individuals
* Doesthe right thing
* Understandsthat people count
* Holdsthemselves to very high standards
* Adaptabilityto changes and competing priorities
* Registered Dental Hygienist (RDH) required
* 2years of Clinical experience working in a dental office (solo, group, or DSO)
* Pastexperience with dental billing is a plus
* Prior investigative claims experience preferred
The above description includes the most significant duties performed. However, other occasional work assignments not mentioned are assumed to be included. Management reserves the right to assign and/or reassign duties and responsibilities at any time.
Every day, Guardian gives 26 million Americans the security they deserve through our insurance and wealth management products and services. Since our founding in 1860, our long-term view has helped our customers prepare for whatever life brings whether starting a family, planning for the future or taking care of employees. Today, we're a Fortune 250 mutual company and a leading provider of life, disability and other benefits for individuals, at the workplace and through government sponsored programs. The Guardian community of ~9000 employees and our network of over 2750 financial representatives is committed to serving with expertise when, where and how our clients need us. Our commitments rest on a strong financial foundation, which at year-end 2017 included $8.0 billion in capital and $1.6 billion in operating income. For more information, please visit guardianlife.com or follow us on Facebook, LinkedIn, Twitter and YouTube.
Guardian? is a registered trademark of the Guardian Life Insurance Company of America.
Guardian is an equal opportunity employer. All qualified applicants will be considered for employment without regard to age, race, color, creed, religion, sex, affectional or sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law.
Associated topics: chart, complete, condition, evaluations, hygienist, mouth, on call, polishing, rda, scaling