Dental Authorization Specialist; MAS​/CQCT

Dental Authorization Specialist (MAS3/CQCT)

This Medical Assistance Specialist 3 (MAS3) supports the mission and vision of the Health Care Authority (HCA) as we work together to provide quality services that enhance our client’s ability to obtain and access health care by providing expert consultative services to providers and clients and determining prior authorization of dental and orthodontic services.

All HCA employees will apply an equity lens to their work, which may include but is not limited to all analyses of core business and processes.

The Clinical Quality and Care Transformation (CQCT) Division is responsible for designing and implementing clinical policy; conducting oversight, including measuring, monitoring, and improving all clinically related programs; and communicating and collaborating with stakeholders, providers, plans, and delivery system partners on clinical activities and issues with the goal to provide a single standard of evidence-informed high-quality care.

This position works within CQCT’s prior authorization section and protects clients from unproven or risky procedures, tests, or medications that may be harmful and do not meet evidence-based guidelines as an effective treatment. This position determines prior authorization of Dental and Orthodontic services, processes prior authorization requests for Exception to Rule and Limitation Extensions and, process improvement and program enhancements.

This position is eligible to telework and is typically not required to report on-site. The default assigned work location of all Health Care Authority (HCA) positions – both on-site and telework eligible positions – is within the State of Washington. This position reports to Olympia, WA. Frequency of onsite work will vary based on business and operational needs. HCA has currently suspended the ability to support out-of-state telework.

• Review, analyze, and process incoming dental and orthodontic prior authorization requests for validity and compliance with the Medicaid Provider Guides, numbered memorandums, and Washington Administrative Codes (WACs). Apply policies, state and federal rules and regulations.
• Evaluate individual dental requests for appropriateness, completeness, compliance with established dental and medical standards, regulations and policies, dental and medical contraindications, and medical necessity. When appropriate, communicate with providers to obtain medical justification for the request.
• While processing requests, maintain an acceptable office error rate of less than three percent.
• Resolve complex issues related to the dental/orthodontic program. This requires professional communication with providers, clients and other HCA staff to resolve complex issues.
• Notify clients and providers of decisions through clear and concise technical correspondence based on medical necessity of the service requested.
• Provide consultative services to providers, HCA staff and other state agency staff with respect to the dental/orthodontic program. Maintain workflow to and from dental/orthodontic consultants.
• Determine client eligibility and whether request requires prior authorization based on program rules and guidelines. Review documents to ensure all required documentation was submitted, if not, notify and educate submitting provider’s office as to what information is required.
• Refer and/or collaborate with Provider Review and Audit Section if specific provider trends are identified where requests seem unusual or inappropriate.
• Investigate, analyze or resolve, through collaboration with the Provider Relations and Claims Processing, regarding claims issues and pricing problems related to services that are authorized.

Qualifying candidates will also meet one of the following criteria options:

• Bachelor’s degree.
• One (1) year of experience working in a dental office setting, which includes a working knowledge of health insurance, disability, or other related health benefits; public assistance eligibility determination; health insurance premiums/claims processing, adjusting, and investigation; or…