Mexico Sr. Clinical Dental Consultant, DentaQuest

Position: New Mexico Sr. Clinical Dental Consultant, DentaQuest
Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.
* Denta Quest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.
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* Job Description:

** Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work in the contiguous states plus AK.
** Candidates must reside in the state of New Mexico
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* The opportunity:

** The Sr. Clinical Dental Consultant reviews claims based on medical necessity, in accordance with market contracts, evaluate appeals, counsel providers, identify providers with aberrant utilization patterns, provide clinical aid for provider outreach, and act as a clinical SME (or liaison) for internal entities.
** How you will contribute:
*** 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 identify if proper documentation has been obtained to deny claim. Make further recommendations, request additional information, review charts, and make revised or reiterate claim decision.
* Reviews authorization requests for anesthesia and rendering judgement on medical necessity.
* Review and render conclusions on all orthodontic claims for handicapping malocclusions specific to each Market contract.
* Communicate claim review outcome to participating Dentists, plan members, and Health Plans.
* Facilitate and give Provider orientations.
* Communicate to management ways to improve processes and productivity of company.
* Develop a full comprehension of the administration of the dental program, including, but not limited to: benefit and authorization requirements for Plans and/or States, claims payment and the denial process, and a business understanding of ASO and Risk relationships.
* Develop knowledge and understanding of state and federal dental regulations, and proactively alert staff of changes that are taking place.
* Provide guidance and education in the provider community on the dental program; provide recommendations in managing the dental program efficiently and effectively.
* Represent the company in a professional manner for the market, including meetings associated with the provider community.
* Proactively seek out opportunities to speak on the benefits of Medicaid and Medicare dental programs.
* Identify community opportunities for the company to participate within, including, but not limited to: health fairs, dental screenings, back to school programs, etc.
* Develop an understanding of the oral health wellness and outreach programs offered, working closely with Dental Consultants and staff.
* Review dental cases to represent the company at fair hearings, as needed.
* Establish relationships with dental associations and key stakeholders in the surrounding region, helping to solidify new business in other states.
* Adhere to business processes.
* Recruit qualified providers for the network.
* Other duties as assigned.
** What you will bring with you:
*** Graduate of an accredited Dental School (D.D.S. or D.M.D).
* An active New Mexico Dental License.
* Orthodontic experience a plus
* Maintain an unrestricted dental license.
* Knowledge of general dentistry.
* Efficient PC skills.
* Ability to use analytical/presentation tools such as Excel and PowerPoint.
* Organizational and time management skills.
* Ability to work with a team and independently to complete assigned tasks without…