Dental Utilization Management Reviewer

BCBSMA is seeking a new Dental Utilization Reviewer to join our elite Dental Utilization Management Division!

Our dental utilization management team reviews certain types of procedures for quality of care, necessity, and appropriateness of treatment based on the documentation submitted. The team includes dentists, dental hygienists, and dental assistants. Based on a review of the submitted procedure documentation, our dental consultants determine available benefits for certain types of procedures, including, but not limited to, cast and milled restorations, periodontal services, oral surgery services, and fixed and removable prosthetics. A dental consultant reviews the treatment plan objectively and determines whether the services are within the scope of benefits, and whether these services appear to be necessary and appropriate for the member. Based on these findings, we may determine that a service is not necessary and appropriate for the member, even if a dentist has recommended, approved, prescribed, ordered, or furnished the service.

This position is eligible for the following persona(s): eWorker, mobile, resident.

RESPONSIBILITIES:

• Review and evaluate dental claims and clinical information to determine necessity and appropriateness of services using established dental policy, guidelines and contracts
• Flexible decision-making outside of policy and guidelines
• Work with dental consultants in the decision-making process
• Review/analyze irregular provider utilization patterns and trends and determine appropriate course of action
• Effectively communicate final disposition of reviewed claims to internal and external customers
• Maintain proficiency in systems and programs
• Review processes and make recommendations to management to improve these processes
• Monitor utilization savings
• Monitor inventory levels and recommend effective inventory reduction plans to management
• Assignments as required by leader

QUALIFICATIONS:

• Demonstrated ability to read and interpret dental radiographs, surgical documentation, treatment notes
• Excellent verbal and written communication skills
• Ability to work in a fast-paced, detail-oriented work environment under tight timeframes and deadlines
• Capacity to work in both a team environment and on individual assignments
• Ability to respond to internal customers in a fast-paced environment
• Proven problem solver who can work under their own initiative
• Proficiency in Microsoft software, Excel, Access
• Excellent organizational skills

EDUCATION & TRAINING EXPERIENCE:

• Minimum 5 years' experience in a dental office environment
• MA Registered Dental Hygienist or MA Certified Dental Assistant
• Knowledge of industry claims billing process

#LI-REMOTE

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.