Gainwell Technologies LLC
Location
Roseville, CA | United States
Job description
Summary
Gainwell Technologies Dental Consultants apply clinical expertise to review, approve, and/or deny dental treatment authorization requests and claims in accordance with CA Department of Health Care Services (DHCS) Medi-Cal Dental policies.
Your role in our mission
- Review dental records to determine medical necessity of oral health services within professionally recognized standards of care.
- Manually adjudicate Treatment Authorization Requests (TARs), Notices of Authorization (NOAs) and Claim Inquiry Forms (CIFs) utilizing standards and procedures set forth by the CA Department of Health Care Services (DHCS) to ensure adherence to Medi-Cal Dental policies and procedures.
- Works within a team of dental consultants, sharing a proportional workload of prior authorization and/or claims processing that have been determined to need professional expertise. These claims have been referred from other members of the Claims Processing team, usually involving special needs patients, and good communication skills are necessary for continuity within the business operations.
- When needed, dental consultants assist with training and orientation of new dental consultants, providing guidance and mentoring, such as job coaching and peer interaction including assistance with complex cases or claims.
- Assists other departments, when requested: a) Claims Processing and Operations, b) Provider and Member Services, c) Grievances/Appeals, d) HR/Onboarding/Interviews, e) Quality Management, f) Peer review, and g) Providing findings to the claims processing team and/or adjudication of claims.
What we're looking for
What We’re Looking For
- A minimum of ten (10) years of prior hands-on, clinical experience as dentist delivering dental services. The candidate must meet all requirements and training set forth by the Board of Dental Examiners in California.
- Possession of active (non-expired) license to practice dentistry in CA, which is in good-standing and free of any suspensions or sanctions from Federal, State, or local jurisdictions.
- Prior adjudication and claims processing for Medi-Cal Dental in California is a plus, but not a requirement.
- Expertise and knowledge of Medi-Cal Dental criteria and program requirements.
What you should expect in this role
- Position will be Hybrid schedules, with On-Site (Roseville, CA) as needed, to be determined.
Job tags
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