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Maintain provider data in vision systems and build constructive working relationships with key individuals at provider offices Set up and maintain accurate and clean provider information in all vision systems. Ensure all data necessary to generate provider payments and reports is captured and accurate in vision systems. Ensure placement of all members for all services administered for vision progr
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Participation and successful completion of the Clinical Review Specialist training program. Review and authorize major dental services based on medical necessity and eligibility, in accordance with contract language. Consistently meet Level 1 productivity requirements (10+ authorizations per hour after 6 months). Maintain acceptable audit and IRR scores within departmental guidelines. Communicate
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Analyzes and evaluates business requirements by working with clients and management. Provides recommendations on the nature, scope and complexity of solutions Acts as Lead by developing and documenting functional and technical specifications and project plans for proposed solutions to business requirements of moderate to high complexity. Develops (codes), tests, documents, educates and supports su
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Manage efforts to implement and revise correspondence, resulting from operation activity forutilization management, claims, and complaints/grievance/appeals, to ensure accurate content within the templates and the templates are implemented or revised within the timelines required. Completion of the client requirement document (CRD) to accurately reflect contract and regulatoryrequirements. Present
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The Application Developer is responsible for the development and implementation of technical solutions. This role will leverage technical expertise in database applications, ETL processes, and automation in support of internal and external customer's data exchange and integration needs This posting is for sourcing purposes for future openings . Once position is active , a representative will reach
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Select, install and manage AIX software and management tools. Provide capacity and utilization reporting to management on a regular basis Provide coordination to develop and refine best practices around existing AIX platforms and hosted services Maintain an "always ready" level of disaster preparedness for the AIX platform and applications. Support and participate in DentaQuest's semi annual Disas
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Strategic and tactical leadership in identifying, interpreting, prioritizing, designing and procuring analyses to help guide business decisions. Partner with business and clinical teams and other internal clients and resources to enable and execute impactful, accurate business analytics and solutions. Bridge solutions to implement with business partners. Develop and maintain deep understanding of
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Determine dollar amount, calculate financial responsibility, and enter Orthodontic Continuation of Care cases based on prior claims submitted, submitted explanation of benefits, treatment plan and other supporting documentation. Review, research and respond to inquiries routed via telephone, follow ups, and email. Investigate and manage orthodontic reimbursement inquiries with Client/Provider Enga
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Analyzes and evaluates business requirements by working with clients and management. Provides recommendations on the nature, scope and complexity of solutions Document the functional and technical specifications and project plans for proposed solutions to business requirements of moderate to high complexity. Develops (codes), tests, documents, educates and supports subsequent software solutions De
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The Director, Business Process Services is primarily responsible for managing all outsourcing operations for DentaQuest and plays a pivotal role in making it a high performing organization. This includes identifying & planning new opportunities for outsourcing for the business as well as enabling the organization to manage a diverse set of business partners who bring needed capabilities to existin
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Enter and maintain Provider applications, contracts and updates into the system. Enter and maintain all Provider information into credentialing database. Verify potential and existing Provider's license, liability insurance, BNDD, CDS and DEA certificate. Verify Provider's education, hospital privileges, Board certification and other criteria as required. Verify accurate banking & billing informat
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Participation and successful completion of the Clinical Review Specialist training program. Review and authorize major dental services based on medical necessity and eligibility, in accordance with contract language. Consistently meet Level 1 productivity requirements (10+ authorizations per hour after 6 months). Maintain acceptable audit and IRR scores within departmental guidelines. Communicate
Posted Today
The Remedial Action Manager implements solutions derived from data driven analysis into client, provider and operational services to achieve desired cost outcomes. Collaborating within the Cost Team, with Client/Provider Partners and throughout the organization, this role recommends technology solutions to address cost initiatives, operations, outlier, program and other solutions influencing outco
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Authorize or deny claims based on medical necessity and eligibility, in accordance to contract language. After clinical review enters claim status into the system. Evaluate appeals and determine if proper documentation has been obtained to deny claim. Make further recommendations, request additional information, review charts, and make revised or reiterate claim decision. Responsible for reviewing
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Preparation of all paper claims requires detailed, robust knowledge of Delta, Commercial, Vision as well as State & Health Plan business clients, client requirements, claim & UM policies and procedures. The preparation of the paper claims includes Identifying specific criteria to determine the correct claim type that accurately identifies the claim ( 8 possible determinations) Assuring that all co
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